mmMim^m DICTIONARY op \ 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 RECOxMMENDED, A CLASSIFICATION OF DISEASES ACCORDING TO PATHOLOGICAL PRIN- CIPLES, A COPIOUS BIBLIOGRAPHY, WITH REFERENCES; AND AN ^ppentrip of &j)j)rotatr iFormttlae: THE WHOLE FORMING A LIBRARY OF PATHOLOGY AND PRACTICAL MEDICINE, AND A DIGEST OF MEDICAL LITERATURE. Zai> BY JAMES COPLAND, M. D. Consulting Physician to dueen 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. VOL. II. CAMBRIDGE : FOLSOM, WELLS, AND THURSTON. 1838. YCB C7?4-d CONTENTS. DEBILITY—Its General States, &c. Its Special Manifestations, Ef- fects, and Relations Its Treatment - - - DEGLUTITION, DIFFICULT - DELIRIUM..... DELIRIUM WITH TREMOR - And Excited Vascular Action - And Exhausted Nervous Power (Delirium Tremens) DENTITION, DIFFICULT DIABETES ..... DIAPHRAGM- -Inflammation of - Organic anc Functional Lesions of ..... DIARRHCEA- . mptoms and Va- rieties - Of Infants. «•-«;. . a sues Df - xoity ttiiu oltua- 473 477 481 486 490 497 497 497 504 506 519 521 522 525 528 536 540 542 544 545 550 tion - v ... 552 DISEASE —Th? Causation and Doctrine of .... 556 Causation of— ^Etiology - - 558 Pathogeny - 571 Alterations of Exhalation and Secretion .... 580 Connection between Alterations of Fluids and Solids - - 593 Procession of Morbid Phenom- ena .... . 594 Terminations ... 596 Its Relations, Successions, and Complications ... 597 DISEASE —Metastasis of - - 599 Circumstances modifying the Form, &c. of DROPSY —Pathology of Treatment - Of the Abdomen Puerperal Ascites - Of the Amnion Of the Cellular Tissue - Of the Chest - - ■ • Congenital - Encysted - In the Head - DRUNKENNESS DUODENUM — Functional Disor- ders of - Inflammation of DYSENTERY —Seat of - Acute . . _ - - Its Type - - - - Its Complications Chronic - Terminations and Prognosis of Morbid Appearances Diagnosis .... Pathological Inferences respect- ing ..... Treatment .... EAR — Nervous Affections of the — Noises in - 735 Earache - - - - 736 EAR — Inflammation of the — Acute Inflammation of the _ - - Chronic Inflammation of the Treatment - ECTHYMA - Description of - Diagnosis—Causes—Treatment ECZEMA — Description Diagnosis - Prognosis—Causes—Treatment 601 603 613 627 633 634 635 641 649 652 660 685 689 690 693 695 704 705 707 709 710 711 713 717 737 739 741 742 743« 744 745 747 748 CONTENTS. EDUCATION, PHYSICAL - 749 ELEPHANTIA— Causes — Symp- toms and Progress — Pathology 750 Diagnosis - . . - 751 Treatment - 752 EMPHYSEMA - - - - 752 Intrinsic — Extrinsic - - 753 Diagnosis — Prognosis — Treat- ment .....755 ENDEMIC INFLUENCES AND DISEASES - - . .756 EPHELIS — Forms and History 765 Treatment - 766 EPIDEMICS — Causes, &c. - - 767 Precursors of - - - - 774 Constitutions of Authors - - 777 General Inferences - - 780 EPIGASTRIUM —Examination of its States - 782 Contusions, &c. - 7H4 EPILEPSY — Description, &c. - 785 Consequences and Terminations 788 Causes - 789 Varieties - 791 Appearances after Death - 796 EPILEPSY—Nature of Diagnosis - Prognosis — Treatment - ERECTILE TISSUE - ERETHISM - - - - Mercurial - ERGOTISM - - - - ERYSIPELAS — General Descrip- tion ------ Particular Description Division of Lesions in Fatal Cases — Diag- nosis - - - - Prognosis — Causes Of Infants - Treatment - ERYTHEMA—Description - Causes — Diagnosis—Treatment EXANTHEMATOUS DISEASES EXCRETIONS —Natural - Morbid..... EXPECTORATION - EYE — Inflammation of the - Inflammation of the External Tissues of - - - - 850 797 798 799 816 816 817 817 818 819 820 824 825 827 828 836 838 839 840 842 846 848 CROUP — Remarks on various Remedies employed in. 469 throat, as recommended by some writers ; and, in very young and delicate children, it will be better not to place them over leech-bites. In the latter periods, I prefer to blisters, the use of warm poultices, on the surfaces of which Cayenne pep- per and scraped camphor are sprinkled in quantity sufficient to produce redness of the cuticle ; or the application of warm cloths, moistened with either of the liniments, F. 300, 307, 308. These are particularly useful upon the removal of the patient from a warm bath, especially in the complications of the disease. Sinapisms have been directed by many to be applied to the extremities ; but I have seen more harm than benefit produced by them, from the distress and crying they occasioned. 63. f. Internal and external emollients are sometimes useful auxiliaries, particularly in the first stage. The decoctum althaea?, the mist. amygdal. dulcis, the inspissated juice of the sam- bucus niger, mucilages, with liquor ammonia? ac- etatis, vinum ipecacuanha?, and syrup (see F. 47. 389.), may be used internally ; whilst warm fo- mentations, with decoction of camomile flowers and poppy-heads, are applied about the throat, and frequently renewed, upon the occurrence of hoarseness, cough, and difficult respiration. These have the effect of retarding the approach of the latter and more dangerous states of the malady, even when they fail of rendering more efficient aid. Lentin advises camphor to be ap- plied to the chest; but it will be more beneficial to employ it along with the fomentations, which may extend over both the throat and the upper part of the chest; or it may be placed upon warm poul- tices, as advised above, particularly in the more spasmodic and complicated states of the disease. 64. i. Cold epithems on the throat have been employed by some writers, and particularly by Field. They appear to have been of little ser- vice in his cases. I am unable to give any opin- ion respecting them from my own experience. They seem not to be equal to warm fomentations. Goelis states, that they are dangerous means to resort to ; and alludes to cases where they were injurious. 65. ?,. Semicupium and pedituvium are useful modes of derivation, in the first and second stages especially. But salt, mustard, and, in some cases, a little of either of the fixed alkalies, or of the sulphurets, should be added to the water, and its temperature gradually increased as immersion is prolonged. Great care is requisite in removing the patient from the bath, to prevent any chill. In many cases, it will be preferable to wring as dry as possible large pieces of flannel out of warm water prepared as above, and to wrap them round the lower limbs of the patient, changing them fre- quently, or prolonging the use of them, according to circumstances, and preserving the bed-clothes from moisture. 66. #. Tepid and warm bathing are of service —the former in the early stages, the latter in the advanced periods, of the disease. Goelis advises the tepid bath of about 23J or 24° of Reaum. ; and to be rendered antispasmodic by using a de- coction of chamomile flowers and poppy-heads ; or irritant, by adding some caustic alkali; or both antispasmodic and derivative, by a combination of these substances, according to the circumstan- ces of the case. I have, in a few instances, used these baths, upon the recommendation of this writer, and certainly with marked advantage, but I have increased their temperature in the latter stages of the disease, rendering them, at the same time, more irritating by the addition of an alkali. In the early periods, however, the emollient and antispasmodic form of bath seems preferable, particularly when the patient breathes the vapour rising from it. The duration of immersion should seldom be shorter than twenty minutes, unless circutiistances should prevent it ; and I am con- vinced that it may be prolonged to two hours, with advantage, in some instances. In a case de- spaired of, I caused, upon the recommendation of Goelis, the child to be put in a bath consisting of a decoction of chamomile flowers and poppies, to which some caustic alkali was added. It was kept there for twenty-five, and on a second occa- sion forty, minutes. It ultimately recovered. Care must be taken that the temperature of the bath does not fall during its continuance. As soon as the patient is removed, and the skin dried, he should be placed in warm flannel or in a blank- et ; and perspiration encouraged by diaphoretics suited to the nature of the case and stage of the disease : in the early stage by antimony or ipeca- cuanha, so as to excite slight nausea, or occasion- ally vomiting, if requisite ; in the latter periods, with liquor ammonia? acetatis, given in sufficient quantity to produce the same effects ; or, if sinking be apprehended, with camphor, ammonia, &c. 67. ;. Prugatives have been given with differ- ent intentions ;—either as mere evacuants of re- tained secretions and excretions ; or as active derivatives from the seat of disease. Home, Desf.ssartz, and MiCHAeLis, seem to have resorted to them with the former intention ; Ham- ilton, Pinel, and Autenreith, with the latter view ; Crawford, Thompson, and others, prescribing also enemata. My own experience is decidedly in favor of this class of medicines ; and of employing calomel, jalap, scammony, &c.,and extract of colocynth, with assafcetida, &c, in ene- mata (§ 51, 52.). 68. Sudorifics are of use only in the early pe- riods of croup. James's powder, and the other preparations of antimony, subsequently ipecacuan- ha, and liquor ammonia? acetatis, or the one com- bined with the other, and given to the extent of exciting nausea, in conjunction with emollients (§ 63.), are important auxiliaries. Goelis re- marks, that Dover's powder is seldom produc- tive of any benefit ; and that sudorifics are never of service in the last stages. Gentle diaphoresis, early in the disease, is undoubtedly beneficial, when the patient drinks freely of emollients ; but he with justice adds, that very copious sweats only increase the disposition to form false membranes of a firm and adherent kind, owing to the evacuation of too large a proportion of the watery parts of the blood. In these opinions, Treber, Hirsch- field, and most of the Vienna physicians, agree. 69. ■/.. Expectorants. — Under this head may be ranked an important part of the remedies pre- scribed in croup. The inhalation of vapours has already been noticed. The experienced Goelis places much confidence in them during the first and third stages ; in the latter of which they often increase the cough, but they favour the discharge of false membranes, by increasing the mucous secretion by aid of which they are thrown off. I have mentioned (§47.) the expectorants in which 470 CROUP —Remarks on various Remedies employed in. my experience has led me to confide. There are very few which have been more generally recom- mended than senega. Archer, Barker, Val- entin, RoYER-CoLLARD, LeNTIH, Maf.RCK- er, Carron, &c. recommend itafter bleeding. Dr. Archer, who attributes the greatest virtues to this medicine, advises it to be given at the same time as calomel, in frequent doses, until it excites vomiting or purging. Goelis and Tre- ber remark, that, although a good remedy in the third stage, it is by no means possessed of those specific virtues attributed to it by Dr. Archer ; and in this I agree with them. It is a useful medjcine in the complications of the disease with malignant sore-throat or scarlatina. Squills are chiefly trusted to by Hufeland, Rumsey, and Maercker, in the latter periods. They should not be exhibited in the more inflammatory states of the malady, until after depletions have been carried sufficiently far, and we wish to procure the expulsion of the concrete exudations formed in the air-passages. They ought to be exhibited in small doses in the remissions, and pushed to the extent of producing vomiting when paroxysms of suffocation occur. After the membranous sub- stances are removed, squills should be altogether laid aside. The sulphuret of potash has been re- commended by Professors Serf, Chaussier, Mercier, and IIecker, in doses of about four grains, given every three or four hours. It is sometimes of much service after depletions. It may be combined with camphor, or small doses of ipecacuanha. 70. ).. Antispasmodics have been very gener- ally prescribed and particularly by Michaelis, Pinel, Schwilgue, Vieosseux, &c, after the decided use of antiphologistic remedies. Home, Cheyne, and Goelis, consider that these med- icines are of little use in common and inflam- matory croup. I am, however, convinced, from extensive experience, that, when the inflamma- tory symptoms are altogether, or even nearly, removed by antiphlogistic medicines, when the disease passes into a spasmodic state, or presents from the commencement a predominance of such symptoms, and when increased irritability be- comes manifest, a judicious exhibition of antispas- modic medicines is often attended with benefit. Musk, either alone or with other medicines, with calomel (.Michaclis and Wigand), with squills, sulphuret of potash, or other expectorants, and with camphor or ammonia, in the last stage of the malady ; * valerian and its preparations, * The chief danger in croup often proceeds from the spasm with which the respiratory passage is affected in the progress of the disease. The obstruction of the tube bv the false membrane and effused matter, seldom of itself causes suffocation ; but rather this lesion, combined with spasm of the muscles of the larynx and membranous portion of the trachea; and, in many cases, exhaustion is superadded, 01 even constitutes the most important change. Depletions alone will nil overcome this disposition to spasmodic action, which is generally observed to supervene at intervals ; the periods elapsing between the paroxysms varying according to the strength and constitution of the child, and the severitv of the disease. But, in many case-, the spasmodic action Is more frequent and more dangerous, and ihe more likely to become associated with convulsions, the weaker the consti- tution and powers of life, and the more those powers have been reduced by copious depletions. After moderate de pletion, therefore, and in many cases even previously to any, such medicines as possess an antispasmodic power, by first acting as nauseants, are of great benefit. j\I. KlMBELL seems to nave partly adopted this view of the disease and of its treatment; but I am confident he has carried it much too far. If his success had been equal to what he conceives it I and assafatida, or any of the other medicines of this class mentioned above, may be employed, either alone, or with expectorants and opiates, particularly when the energies of the system be- gin to be depressed, or the complaint assumes from the first a spasmodic character. 71. Of those medicines which are antispasmod- ic from their sedative operation, the most impor- tant are colchicum, opium, hyoscyamus, prussio acid, digitalis, and tobacco. Colchicum may be given combined with calomel, in the early and inflammatory states of the disease, or with am- monia or camphor, at a later period ; but it ought, in young children especially, to be exhibited with extreme caution,—in very small doses, and care- fully watched. It came into fashion in this and other diseases of the air-passages a few years since, and was, for a time, much employed ; I then saw some cases of croup in which it had been very injuriously employed, from having been given in too large doses for the age of the child, or too long continued, or combined with other depriments, as antimony, &c, or exhibited after very large depletions. I can most truly assert, that I have seen at least two cases of croup, in | which death was to be imputed to this substance, : rather than to the effects of the disease ; and yet it is sometimes of use when combined as I have now advised. Of digitalis I have had no expe- rience in this complaint ; if exhibited at all, it should be conjoined with calomel. Prussic acid has been employed in some cases which I have I seen ; but the same objections I have urged against t colchicum apply to it, when prescribed for young ! children. In older patients it is sometimes of j benefit, combined with camphor, or oxyde of [ zinc, or other stimulating antispasmodics, in com- I bating the irritability and disposition to spasmodic paroxysms in the latter stages. Opium was much | to have been, the cases which he has met with have been | unusually slight. There is no doubt of bleeding, blistering, purging by calomel, &c. &c, having been pushed to hurtful I lengths in many cases, or inappioprialely applied; and the I same may be said as to other means, which have tended I more to exhaust the vital energies than to cure the disease: and there can be no doubt of the disposition to spasm becom- ing greater, and of its consequences being more to be dread- ed, the lower ihe powers of life sink ; for, with such sinking, the general sensibility and irritability of the frame increase. But 1 cannot conclude that thos; means could have been dispensed with in any considerable number of the cases which have fallen under my observation, and in which I have never omitted also to employ antispasmodics of the most active nature, from a conviction that the disease partly depends upon spasm. Mr. K.'s observations as to the treatment of the disease, are to the following effect:—" I never bleed or blister a child in croup : I have never thought it requisite to do so, since I have adopted the plan alluded to; although such auxiliary practice would be in no other respect incom- patible, than as tending to invalidate the general strength. The treatment I allude to consists in confining the child to a uniform and rather warm temperature, giving an emetic of ipecacuanha, and, in an hour after, commencing the follow- ing mixtuie : — No. 164. Ii Pulv. Valeriana? ^ij.; Oxymel. Scillae 5j-i Tinct. Opii gtt. xx.; Aquae Destillatae Jj. .Misce. I administer a teaspoonful every hour, if the child is from two to five years old ; if from five to eight, every five and forty minutes, so as to maintain the anodyne effect of opium, and the sub nauseant expectorant, antispasmodic effects of the squill and valerian, until the symptoms are removed; which commonly happens in ten or twe lve hours, and which I have never seen protracted beyond eight and forty. On their subsidence, I have, in general, given a brisk dose of calomel and jalap." Mr. K. likewise recommends the above treatment in hooping cough and in catarrh ; and in those cases which are unconnected with inflammatory action, it is not inappropri- ate. In the slight and more spasmodic states of croup, it also will prove very beneficial. • CROUP—Prophyl actic Treatment. 471 employed, after depletions, by Kendrick and Huggans. It may be used both externally and internally (as may the preparations of morphine,) with aromatics, camphor, or assafoetida, musk, &c, in the states of the disease now mentioned. Henbane, and extract of poppy, may also be em- ployed under similar circumstances and forms of combination. Tobacco has been prescribed in croup, in various modes. Dr. Vanderburgh and Dr. Godman recommended a plaster covered with Scotch snuff to be applied across the top of the sternum ; and myself anaWhers have employ- ed this substance, with the vrew of detaching the false membrane by exciting sneezing and an in- creased secretion of mucus. The smoke of tobacco has also been directed to be inhaled, in order to remove spasm, and promote expectoration, by its direct operation in the air-passages ; and others have advised the patient to smoke a cigar, with the intention of producing nausea, as well as the other effects last enumerated. After depletion, and when the disease is about its acme, the powers of life not being materially exhausted, a cautious use of this means may be serviceable. In the case pf children who cannot use a cigar, the smoke of one may be blown around them, and in this way it will have a sufficient effect. Cloth moistened with an infusion of tobacco may, under some circumstances, be applied over the throat, and its effects carefully watched ; but this measure is not without hazard, particularly after lowering remedies have been used, or in an ad- vanced stage of the malady. 72. u. The. preparations of ammonia have been much employed in all the states of croup. Caus- tic ammonia, in doses of three or four drops, given every hour ; ammoniacal liniments being at the same time applied about the throat ; has been ad- vised by some writers, in order to promote the excretion of the concrete exudations in the third stage of the disease. The carbonate of ammonia has been more generally employed. M. Rechou prescribed it both internally, and externally in ointments to the throat. In the latter stages, as a useful antispasmodic stimulant, it may be some- times of service ; it is very advantageously com- bined with camphor, or even with calomel, in the complications of croup with angina maligna, or with any of the eruptive fevers. M.Chamerlit has recommended the muriate of ammonia to be taken internally, and applied to the fauces, when the disease is associated with inflammation of the. throat. The cuprum ammoniatum, and the hydro- sulphuret of ammonia, have also been prescribed in doses suitable to the age of the patient. They may be sometimes of service in the more spas- modic states ; but I have had no experience of their effects in this complaint. 73. v. M. Valentin has recommended the ap- plication of the actual cautery upon each side of the throat, in the most severe forms of the disease, when it is at its acme. Moxas seem to be pre- ferable to the actual cautery ; and, if this practice should be adopted, it might, perhaps, be advan- tageous to follow it by fomentations placed over the trachea. M. Dupuytren employed in one case, referred to by Guersent, a small rod of whalebone covered by pieces of sponge, which was introduced into the pharynx in order to remove the partially separated portions of false membrane lodged in that situation, or partly thrown out from the larynx. In the advanced stage of croup complicated with angina pharyn- gea, this contrivance is calculated to succeed. 74. £. Tracheotomy.—There does not seem to be a chance of success from this operation in any case wherein the treatment developed above has failed. The practitioner, however, may be called to a case so late in the disease, and where the suffocation is so imminent, that the propriety of having recourse to it may be admitted : but, even in these, the chances are infinitely greater against than in favour of its success ; and if benefit can be obtained from any measure, it is as likely to accrue from the energetic exhibition of suitable emetics as from tracheotomy. Cases have doubt- less been recorded of the success of the operation in croup; but these are so very few, compared to the number in which it has failed, that I per- fectly agree with Goelis, Cheyne, Royer- Collard, Porter, Wood, and many others, in concluding that it should seldom or never be attempted in this disease. Of the propriety of having recourse to it in certain states of laryngi- tis, &c. there can be no doubt; and it may, with some slight grounds of hope, be resorted to when croup is chiefly confined to the larynx and upper portion of the trachea ; also, perhaps, in some cases of its consecutive occurrence upon inflam- mation of the throat with membranous exudation; and when we infer, from the general symptoms and the signs furnished by the stethoscope, that the bronchi and lungs are unaffected ; but in that period of the simple as well as of most of the complicated forms of the disease, in which only it should be attempted, and when internal treatment has failed, I believe that the superin- duced lesions in the bronchi, lungs, circulating fluid, and nervous system, are such as to pre- clude hopes of its success. Moreover, the feel- ings of the parents regarding it, and the reputation of the physician and operator, are not to be kept out of view. "Ad tracheotomiam," says Goe- lis, " omnium remediorum incertissimum con- fugere res ardua est; parentes abhorrent, aver- santur agnati et periclitatur medici fama, quern, infausta si fuerit operatio ac votis illudens, lacry- mis multis velut homicidam prolis amata? detes- tantur parentes." 75. ii. Prophylactic Treatment, &c.— A. Goelis states, that he never saw a child with porrigo and other chronic cutaneous affections at- tacked by croup whilst they remained fully devel- oped, even when this disease was most prevalent. He therefore advises the having recourse to any form of issue, when an attack is dreaded. To re- sort, however, to emetics, to antimonial medicines, to counter-irritants, to depletions, to confinement in-doors one half of the year, and other measures which have been advised, is attended with greater mischief than to allow the child to run the slight risk there is of his having the disease. The case, however, is different in respect of a child who has once suffered an attack. The liability of croup to recur, even several times, after intervals of various duration, renders precautions, under such circumstances, very requisite. The chief of such measures are — removal from the predispos- ing and exciting causes (§ 24— 31.) ; change of air and locality ; the use of the shower or cold bath every morning, the skin being well rubbed with a hard or coarse cloth afterwards ; the wear- ing of flannel next the skin, and of a neckcloth in winter and spring ; light nourishing diet, with 472 CROUP — Diet and Regimen. strict attention to the secretions and excretions ; immediate recourse to medicine upon the appear- ance of catarrhal or croupal symptoms ; and a careful avoidance of exposure to cold and moist- ure. When croup occurs in one child of a family residing in situations where it prevails, more will probably be attacked. In such cases, removal to a healthier air is requisite. When it is prevalent either in a simple or complicated form, and particularly when the locality also in- creases the risk of seizure or relapse, the occa- sional exhibition of small doses of calomel and James's powder, or of hydrarg. cum creta with the sub-carbonate of soda, or the having recourse to either of them every second or third night, may be tried. In this country, care should be taken not to expose children to the north-east winds of spring, particularly when they follow heavy rains, &c. 76. B. The Diet and Regimen, in the more acute and inflammatory forms of croup, should be strictly antiphlogistic ; and all food should be withheld until the stage of exhaustion supervene, when, if light nourishment can be taken, or be de- sired, it should be given. In the more spasmodic or prolonged forms, light food may be taken in small quantity. The best beverage of which the patient can drink, is a very weak decoction of marsh-mallows and liquorice root, to which a little candy and sub-borate of soda are added. The temperature of the room should be moder- ately and equably warm. 77. C. During Convalescence, change of air, as soon as it can be safely permitted, is especially beneficial; and strict attention ought to be paid to the prophylactic means stated above (§ 75.), in order to prevent a relapse or recurrence of the malady. These precautions are required during, and for some time after, recovery from the com- plications and consecutive affections of croup, as well as from its simple forms. In the winter and spring months especially, the convalescent should be kept in apartments moderately and as equably warm as possible. BiBLlOG. and Refer. — Hippocrates, Coacre Praeno- tiones, cap. iii. edit. Vandcr Linden, vol. i. p. 555.—Ballo- nius, Epid. Ephemerid. I. ii. p. 197. 201.— P. Blair, Miscel. Obscrv. in the Practice of Physick, k.c. Lond. 1718.— Ghisi, Lettere Mediche. Cremona, 1749, art. 2 —Starr, in Philosoph. Transact. No. 495. for 1749 and 1750. — Simp- son, De Asthmate Infantum Spasmodico. Ed. 8vo. 1761. — fVilclce, De Angina Infantum Recentior. Annis Ob- servata. Upsalae, 1764. — Van Bergen, De Morb. Trucu- lentolnf. fcc, in Nov. Act. Nat. Curios, t. ii. p. 157. Lips. 1764.—Home, Inquiry into the Nature, Cause, and Cure of Croup. Edin. 1765.— Halenius, in Fortsattuing of Provin. Doctorernas Berattelser. Stockholm, 1765. (Contagious.) — Wahlbom, in Ibids p. 181. (Contagious.) — Bard, in Amer. Philosoph. Trans, vol. i. p. 322. — Millar, Observ. on the Asthma and Hooping Cough, 8vo. Loud. 1769. Crawford, De Angina Stridula. Edin. 1771. — Russel, The fficonomy of Nat. in Acute Dis. Lond. 1775. — Rush, on the Spasm. Asthma of Children, &c. Lond. 1770. — Michailis, De Angina Polyposa. Goet. 1778.— J. Johnstone, On the Malig. Angina, with Remarks on Angina Tiachealis. Worcest. 1779. — Bayley, Cases of An• «• it. & P^n180-"T^"^ In Ibid. b. ii. p. 167/} et Beytrage, b. i. p. 300., b. in.J-,B* -Maerclcer, in Hufeland's Journ. dei P act. HmIK. fc xi, ,t. 3. ^■-/f'^X^iot^ vol' ii. S.Vn^vnaUe Trachelitis Med. Inquire. and Observat. 'Lond. 1789, «">• ~ ^""C*"^^ ,„i* vi Med. Renos, vol. iii. p. 340. -B»rker, in Ibid. voI. vi. ... o _po~t„l M^nnire sur Plus. Malad. t. 1". p. po. art 3 -Portal, Memoire sur Plus. Malad. t. m. p. <». -> M'Grigo - in Edin. Med. and Surg Journ. vol ,. „ 9ML- rLou. in Journ. Gener. de Med. t. xx. p. 3. A.inalen, Dec. 1810.£ 512.-fVichmann Ideen zur Diagnostic b. ii. p. ioST; et in HuJeland', Journ. d. Pr. Arznevk, b. i. p. 21.-Giraudy, De I 'Angme Tracheal* Paris,'1811. — Eschenmayer, Die Epidem. des Croups zu Kirchheim. 1807. 8vo. Stut. 1811. - Cheyne, Pathol, of the Memb. of Larvnx and Bronchia, 8vo. fcdin. 1809.— Ro^eni, in Journ". Gtn. de Med. t. xxxvin. p. 153.— Heim, in Horn's Archiv. 1810, p. 379. — Neumann, m Ibid. Mart. 1811, p. 234. — Schaffer. in Ibid. July, 1811, p. 155.; et in Hufeland's Journ. d. Pr. Heilk. Nov. 1810, p. 80. — Double, Traite du Croup, 8vo. Pans, 1801.— Chaussier, in Journ. de Med. Contin. May, 1811, p. 74., et Dec. p. 455.—Leeson, in Med. and Phys. Journ. Nov. 1801. — Wainwright, in Ibid. April, 1800. — Willan, Reports on Dis. of London. Lond. 1801. 8vo. — Latour, Manuel sur le Croup. Paris, 8vo. — Chamerlat, Journ. de Med. ice. t. xxvii.__Royer-Collard, in Diction, des Sciences Med. t. vii. p. 412.—Chevalier, in Transac. of Med. Chirurg. Soc. vol. vi. p. 151. — Mercier, in Journ. Univers. des Sc. Med. &c. t. xiv. p. 225.—J. A. Albers, Comment, de Tra- cheitide Infantum, &c. 4to. Lips. 1816. (Obtained theprizi given by Napoleon.) — L. A. Geolis, Tract, de Rite Cog- noscendi et Sananda Angina Membranacea, 8vo. Vien. — Grimaud. in Journ. Complem. des Diet. de» Scien. Med. Jan. 1822. — Author, in Lond. Med. Repository, vol. xix. p. 46. — Schmidt, Journ. des Progres des Scien. Med t. ix. p. 244. — Lobstein, in Memoir, de la Soc. Med. d ' Emulation, t. viii. p. 500. — Louis, Memoire: Anato- mico-Pathologiques, 8vo. Paris, 1826, p. 203.; et in Ar- chives Gener. de Med. t. iv. p. 5. et 369. (In the adult.)— Reddelin, in Philadelph. Journ. of Med. Science vol. v. p. 201. (Snuff in.)—Hoffmann, in Ibid. vol. vi. p. 409. (Sulph. cupri.)—Valentin and Wigard, in Lond. Med. Repos. vol. i. p. 122. 285. 48.—Serf, in Ibid. vol. iv. p. 143. 464. (Potassa sulphur.) — Schmidtmann, Observ. Med. vol. ii. p. 24.— Editor of Quarterly Journ. of For. Med. vol. v. p. 618. — J. B. Lucroix, D'Une Epidemie de Croup, &c. 8vo. Paris, 1822.; et in Nouv. Journ. de Med. t. xiv. p. 176.— Godman, in Journ. de Progres des Scien. Med. t. xiv. p. 249. — Blaud, Nouv. Rech. sur la Laryngo-Tracheite, &.C 8to. Paris, 1823. ; et in Nouv. Biblioth. Med. t. iv. p. iO.—Billard, in Archives Gener. de Med. t. xii. p. 544.,el t. xx. p. 491. — Ouvrard, in Ibid. t. xii. p. 631. {Epidem- ic.) — Guersent, in Ibid. t. xvii. p. 493. — Bretonneau, in Ibid. t. xiii. p. 5., et t. xxiii. p. 387. 519. (Comp. with ung. pharyngea.) — Villeneu-oe, in Ibid. t. xviii. p. 308. (Wm ang. pharyng.) —Horteloup, in Ibid. t. xviii. p. 57.—Bow* geois, in Ibid. t. xix. p. 134. (Comp. zvith ang. fave.)— Giraudet, in Ibid. p. 586. — Trousseau, in Ibid. t. xxi.p. 541. (Comp. with scarlatina.)—Emangard, Amer. Journ. of Med. Sciences, vol. vi. p. 181. — Vanderburgh and God- man, in Ibid. vol. ii. p. 480. — S. Jaclcson, in Ibid. vol. iv. p. 361. —Hosaclc, On Croup, in Essavs on var. Subjects of Med. Science, vol. ii. p. 133. N. Y. l'824. 8vo. — Balliard, in Journ. Hebdoin. t. iii. p. 113.—Deslandes, in Journ. des Progres des Scien. Med. t. i. p. 152. — Moronval et Laviez, in Rev. Med. t. ii. 1825, p. 147. — Mackenzie, in Edin. Med. and Surg. Journ. vol. xxiii. p. 294.—Robert- son, in Ibid. vol. xxv. p. 279. — Pretty and Sym, in Med. and Physical Journ. for Jan. 1826. — G. Gregory, in IMd. Oct. 1825. — J. Hamilton, Edin. Journ. of Med. Sciences for October, 1836. —Matins. De Cynanche Trachealia, 8vo. Edin. 1830. — Guersent, in Diet, de Medecine, t. vi. p. 211. — H. M. J. Desruelles, Traite Theoriq. et Pratique du Croup, 8tc. 8vo. Paris, 1821. — T. Guibert, Rccherchea Nouvelles sur la Croup, et sur la Coqueluche, &c. 8vo. Paris, 1824. — P. Bretonneau, Sur la Diphtherite ou In- flam. Pelliculaire connue sous le Norn de Croup d'Angine Maligne, &.c. 8vo. Paris, 1326.—jr. H. Porter, On the Surgical Pathol, of the Larynx and Trachea, with relation to the Operation of Broncho'tomy, he. 8vo. Dublin, 1826. — Kimbell, in Lancet, vol. xvii. p. 160. — Bricheteau, Pre- cis Anal, du Croup, et de l'Angiue Couenneuse, &c, et Rap. sur les Memoir, env. au Concours sur le Croup, tc, par Royer-Collard, &lc. 8vo. Paris, 1826.—Jurme, in Rapport du Royer-Collard, in Ibid. _ Mills, On the Morbid Appear, of the Trachea, &c. 8vo. Dub. 1829.— Wood, in Transac. of Med. and Chirurg. Society, vol. xvii. p. 169. DEBILITY — Divisio CYANOSIS. See Blde Disease. CYNANTHE MALIGNA. See Fever, Scar- let; Fauces; and Pharynx, Inflammations of CYNANCHE PAROTID^EA. See Parotid, Inflammation of. CYNANCHE PHARYNGEA. See Pharynx, Inflammations of. CYNANCHE TONSILLARIS. See Tonsils, Inflammations of. CYNANCHE TRACHEALIS. See Croup. CYSTITIS. See Urinary Bladder, Inflam- mations of. DEAFNESS. See Ear, Diseases of; and Hear- ing, Disorders of. DEBILITY.—Syn. Adynamia, Asthenia, Ato- nia, Debilitas, Lat. Die Schwasche, Schwas- chheit, Ger. Debilite, Asthenie, Fr. Debolez- za, Ital. Vital Depression, Diminished Vital Power or Energy. Classif.— General Pathology; Pa- thogeny.— Special Pathology. I. Class. 1. Defin.—That departure from the healthy condition of the frame, which consists of a dimi- nution of its vital energies—of an enfeebling of its powers, manifested in numerous conditions and grades throughout the whole frame, or more or less remarkably in particular systems or organs. 2. Debility is a state of vital manifestation inti- mately connected with the nature of disease1; and, in whatever acceptation it has been understood, it has been admitted by every physician who has looked beyond the grosser and more palpable changes superinduced in the economy, as not only a most important pathological condition, but as often constituting what is, in the common language of medicine, disease itself. It often performs a principal part in the commencement, and towards the close, of the most severe maladies ; and its modifications are amongst the most difficult in pa- thology to detect and to interpret aright. Several of the appellations it has received have been more or less' restricted to certain of its conditions; as adynamia, to want of muscular or animal power; atonia, to deficient vital tension and tone of cir- culating and exhaling vessels; asthenia, to de- pressed energy of organs essentially vital, &c: but as the distinctions between them have never been made with sufficient precision, and have seldom been preserved, and as they have all been used synonymously by the best modern writers, they will be thus received at this place. 3. It might appear interesting to ascertain the varieties and -grades of debility ; but this is a matter of no easy accomplishment, if not entirely beyond the reach of our powers. Debility is, besides, a relative term ; and of its extent or de- gree of departure from that condition of vital power requisite to the perfect performance and continuance of the functions, we can form no very precise idea, even were we agreed upon the standard of power by which the comparison should be made. Of its numerous grades and manifestations, from the slightest departure from health to the utmost consistent with existence, there can be no question ; and therefore they cannot be otherwise than arbitrarily appreciated. This will appear obvious to any one who will re- fer to the numerous varieties into which Vogel and Sauvages have divided asthenia. i of its Conditions. 473 4. Divisions of. — It will be preferable, therefore, to consider debility in respect merely of its principal conditions relatively to the opera- tion of the chief causes which induce it; and, in order to elucidate its morbid relations, and its influence in producing and perpetuating further disease, to enquire into its manifestations and ef- fects on the various general systems and org ins of the body. The majority of pathological writ- ers have found great difficulty in considering this subject, and scarcely any two have agreed as to the manner of discussing it, or as to its nature. Some have viewed it as the negative of excitation, or a minor degree of that state of excitement in- duced in the system by the agents surrounding and acting upon it, —by privation, or change of the factors of life (Hartmann.) This opinion, which may be traced to the Slrictum and Laxum of Themison ; but which was first insisted on, in a manner at all accordant with the doctrine of solidism, by Brown, and variously modified and illustrated by his contemporaries and followers; led to the division of this grand pathological state into two forms, — direct and indirect debility. This division was adopted by Darwin ; and Rush followed the same track, denominating the former debility from abstraction, the latter debility from action. Rasori and Tommasini hafdly even modified the doctrine of Brown, when they divided it into primary and secondary; the former arising from contra-stimulating, the latter from stimulating, impressions. Broussais followed a similar arrangement; but considered that it is primary in very few instances, and only from the abstraction of stimuli. The simplicity of these divisions is their chief recommendation; but it is carried so far as to be inconsistent with the com- plexity of those derangements to which the human frame is subject. This feeling seems to have in- duced Boisseau to impute it to three sources: 1. To a complete or prolonged abstraction of the accustomed stimulus; 2. A diminution of the re- ciprocal stimulating influence of the organs; and 3. To the inordinate excitation of a part, render- ing the others incapable of acting with energy. M. Brachet, a'dopting similar views to my own, but several years after mine were published, both in the London Medical Repository and in my Physiological Notes, refers debility either to diminution of the action of the cerebro-spinal sys- tem, enfeebling the functions over which it pre- sides, or to depression of the functions dependent upon the influence of the organic or ganglial nerves; the weakness of the nervous system aris- ing, as he thinks, either from deleterious states of the blood, or diminution of its quantity. Hufe- land divides it into true, and apparent or false} the one from change of the nervous sensibility, the other from oppression of the vital powers. Dr. Geddings, the most recent writer on the subject, considers debility, 1st, as direct, when arising from the abstraction of stimuli, or the operation of contra-stimuli, or such substances as " directly enfeeble the organization ; " 2dly, as indirect, or that resulting from exhaustion, and " from deterioration of the nutritive molecules of the blood; " and, 3dly, as metastatic, or that form proceeding from inordinate irritation of one organ leaving the others in a minor state of excitation. It is impossible to examine the conditions of de- bility with any degree of precision abstractedly — Primary. on the vegetable creation; plants being pale, sickly, and imperfectly developed, and their P'op- er juices scantily and insuthc*nUy ela* rated AnJana.ogous effect l^t^^ cause on the animal creation, anu V i on man-the body becoming pale, ckly, :and etiolated; the senses remarkably acute the gen eral sensibility and muscular irritability much heightened; the organic actions readily influenc- ed by the slightest external agents;* and the circulating fluids thin, watery, and deficient in albuminous constituents and red globules, and id quantity. Facts illustrative of this occurrence are adduced in the article on anaemia, which is there- k„ n^n.pH (Spr Blood, Deficiency of, § 41.) 474 DEBILITY from their principal causes. I shall, therefore, with due regard to this connection, consider, 1st, The primary or direct states of debility: 2dly, Its consecutive or secondary conditions; and, 3dly, Those forms, consisting not only of depressed, but of otherwise morbid or vitiated, vital manifesta- tion — or complicated debility. After having dis- cussed these topics, with reference to general debility, the more special or partial states of de- bility, and its consequences, will be brought into view; and the subject pursued in its relation to general and special pathology. 5. I. Conditions of Debility.—i. Prima- ry Debility (Direct, Brown; True, Hufe- land; from Abstraction of Stimuli, Rush and Boisseau.) This state of debility is not so fre- quent as is commonly supposed, although by no means so rare as Broussais and his followers contend. Many of the cases commonly imputed to it strictly belong to the other conditions specifi- ed above (§ 4.). Primary debility may be, (a) Original, or congenital; and (6) Acquired.—A. The former of these is observed in the children of exhausted,dissipated, or aged parents,—especially the male parent,— and is familiar to every com- mon observer. It also presents itself in the infants of those who are of a strunous diathesis, although generally in a slighter grade, and more frequently obscured by concurrent disease of particular or- gans. This form of debility seldom continues long without being followed by some specific malady, which it either remarkably favours, or even more directly produces, — causes, which are innocuous as respects infants of originally sound stamina, variously affecting, and ultimately blighting the debilitated offspring. 6. B. Acquired debility presents itself to our notice in every stage of life. If it supervene in infancy and childhood, it may be, to a certain extent, perpetuated in the constitution through life. But, in whatever period it may occur, it is most frequently the consequence of the ab- straction of stimuli necessary to the excitation and perpetuation of the vital manifestations to a requisite extent.—(a) The infant that is not suf- ficiently, or is injudiciously, or unnaturally, nour- ished, if it escape any of the maladies to which it is thereby disposed, becomes pale, languid, soft, and enfeebled, or altogether diseased: it wastes; its flesh is flabby; its growth is impeded; and it at last is the subject of anaemia, or of tubercles, or of worms, or of disease of the digestive canal, of the mesenteric and other glands, or of the joints and bones. But insufficient or inappro- priate nourishment affects all periods of life in nearly a similar manner. A fish diet through life gives rise to a weaker conformation of body than food of a mixed kind. This was proved by Peron in respect of the natives of Van Diemen's Land. Similar effects follow an ex- clusively vegetable diet, although not to so mani- fest a degree. It should, however, be admitted that those who are obliged to live on one kind of food alone, are more liable to experience insuffi- cient supplies of it. — (6.) The abstraction of the ■ animal warmth is another cause, occasioning a modified, and, as it were, an acute form of debil- ity, followed by peculiar effects, which are fully described in the article Cold. — (c) The pri- vation of solar light lias a marked influence The physical and mental debility resulting from confinement in dungeons and dark cells is to be attributed to the exclusion of light, restricted diet, want of exercise and of free air, and to moral causes combining with these in depressing the vital * Th- remarkable and authentic history of CasPEH Hauser, by the President Von Feuerbuch, furnishes striking illustrations of the above. The accounts which have been recently published of this person should be at- tentivelv i.erused'by every pathologist and philosopher, as being most singular and instructive. Casper Hauser was kept, from infancy until h ■ was eighteen years of age, in a perfectly dark cage, without leaving it; aud where he neither saw a living creature, nor heard the voice of man. He was restricted from using his limbs, his voice, his hands, or senses; and his food consisted of bread and water only, which he foun 1 placed by him when wakening from sleep. * When exposed in Nuremberg, in 1828, he was consequently, at eighteen years, as if just come into the world ; and as incapable ot walking, decerning objects, or conveying his impressions, as a newly born infant. These faculties he, however, soon acquired ; and he was placed unter an able instructor, who has recorded his history. Darkness had been to him twilight. The light of day at first was insupportable, inflamed his eyes, and brought on spasms. Substances, the odour of whiph could not be perceived by others, produced severe effects in him. The smell of a glass of wine, even at a distance, occasioned headach; of fresh meat, sickness, Sic.; and of flower- painful sensations. Pa sing by a churchyard with Dr. Dal'MER, the smell of the dead bodies, although altogether imperceptible to Dr. D., affected him so powerfully as to occasion shudderings, followed by feverish heat, terminating in a violent perspira- tion. He retained a great aversion, owing to their disa- greeable taste aud smell, to all kinds of food excepting bread and water. When the north pole of a small magnet was held towards him, he described a drawing sensation proceeding outwards from the epigastrium, and as if a cur- rent of air went from him. The south pole affected him less ; and he said it blew upon him. Professors DAUMER and Herrminn made several experiments of this kind, and calculat d to deceive him; and, even although the magnet was held at a considerable distance from him, his feeling always told him very correctly. These experiments alwiu" occasioned perspiration, and a feeling of indisposition. He could detect metals placed under oil-cloths, paper, &c,by the sensations they occasioned. He described these sensa- tions as a drawing, accompanied with a chill, which ascend- ed, according to the metal, more or less up the arm ; and were attended with other distinctive feelings, the veins of the hand exposed to the m^tal becoming visibly swollen. The variety and multitude of objects which at once came rushing upon his attention when he thus suddenly came into existence — the unaccustomed impressions of light, free air, and of sense—and his anxi ty to comprehend them — were too much for his wi-ak frame and acute senses : he became dejecte I and enfeebled, and his nervous system morbidly elevated. He was subject to spasms and tremors ; so that a partial exclusion from external excitements became for a time requisite. After he had learned regularly to eat me it, his mental activity was diminished ; his eyes lost their brilliancy and expression; the intense application and ac- tivity of"his mind gave way to absence and indifference; and the quickness of apprehension became diminished. Whether this change proceeded from the change of diet, or from the painful excess of excitement which preceded it, may be questioned. My limits admit not of my adding more. The whole account is most important — the'more so, as the physiological facts stated in it may be relied on. DEBILITY — Consecutive. 475 powers, and ultimately producing disease of a I low and dangerous form. — (d) Intimately con- nected with this cause and its effects, is the pri- vation of fresh air and exercise. When muscular action cannot be performed under favourable cir- cumstances, particularly as respects the requisite renewal of air, the circulation languishes, and suffers deterioration; the developement of the locomotive organs is either impeded or prevent- ed, and they are no longer in a fit state for the execution of the acts of volition. By a want, also, of a requisite renewal of air, the stimulat- ing constituent of it becomes diminished, and re- placed by directly sedative gases, and by vapours loaded with the effluvia of the system that respires it, or of those which may respire it in the same place; the extent of the stagnation or confine- ment of air, and of the causes of deterioration, proportionately heightening and accelerating the depressing effects thereby produced upon the frame. — (e) It is extremely probable, that what- ever, in its passage through the digestive canal, or circulation through the body, abstracts oxygen from the system, will be also, to a certain extent, a cause of debility, as supposed by Humboldt. The causes of scurvy may be partly of this de- scription; as well as those of several other dis- eases. — (/) A not uncommon cause of depres- sed vital power is the young sleeping with the aged. This fact, however explained, has been long remarked, and is well known to every un- prejudiced observer. But it has been most un- accountably overlooked in medicine. I have, on several occasions, met with the counterpart of the following case: — I was, a few years since, consulted about a pale, sickly, and thin boy of about five or six years of age. He ap- peared to have no specific ailment; but there was a slow and remarkable decline of flesh and strength, and of the energy of all the functions — what his mother very aptly termed a gradual blight. After inquiry into the history of the case, it came out that he had been a very robust and plethoric child up to his third year, when his grandmother, a very aged person, took him to sleep with her; that he soon afterwards lost his good looks; and that he had continued to decline progressively ever since, notwithstanding medical treatment. I directed him to sleep apart from his aged parent; and prescribed gentle tonics, change of air, &c. The recovery was rapid. But it is not in children only that debil- ity is induced by this mode of abstracting vital power. Young females married to very old men suffer in a similar manner, although seldom to so great an extent; and instances have come to my knowledge, where they have suspected the cause of their debilitated state. These facts are often well known to the aged themselves, who consid- ered the indulgence favourable to longevity, and thereby often illustrate the selfishness which, in some persons, increases with their years.—(g-) It is extremely possible that whatever conducts the electricity of the body from it, will occasion direct debility. With this view I have long been in the habit of causing females who used steel supports to their stays, to lay them altogether aside. The experiments on Casper Hauser confirm this supposition.—(h) Intimately related to the causes consisting of abstraction of requisite stimuli, and to the effects resulting therefrom, seem to be the privation of those excitants to which the frame has been long habituated; although these, as well as their effects, may be considered as falling more strictly under a different section of this subject. The privation, by whatever cause, of those states of electrical tension which exist in healthy con- ditions of the body, and fright, or prolonged fear, may also occasion primary debility. 7. C. But the vital power is enfeebled by an- other class of causes — by agents which seem di- rectly to depress it below its healthy standard. These agents have been called contra-stimulants by the Italian physicians of the school of Rasori. — (a) Several of those, however, when employ- ed in sufficiently small quantities, actually excite the parts to which they are applied; and it is only when they are used in large doses that an oppo- site effect — violent depression and even annihila- tion of life — is produced. A minute quantity of prussic acid, or of tobacco, excites the organic functions; a large quantity instantly destroys life: and the remark applies, to a certain extent, to nearly all the more energetic narcotics; although many of them, as well as several other agents, whilst they depress the vital manifestations gen- erally, also excite or irritate particular organs or tissues. Tartar emetic, acetate of lead, oxalic acid, colchicum, stramonium, belladonna, &c. furnish illustrations of this fact. — (b) The prima- ry effects of terrestrial effluvia or malaria, and of the infectious emanations proceeding from the diseased, as from those affected by.plague, yel- low fever, typhus, and pestilential cholera, are evidently most acutely debilitating, even although these causes may also, and at the same time, act by irritating certain organs or tissues. — (c) Vari- ous mental emotions are also very powerful de- priments of vital power, such as fear, anxiety, grief, longings after objects of affection, nostalgia, &c, particularly if they be of long continuance: they retard all the organic functions, and at last wither the whole organization. — (d) Whatever impedes respiration, owing to the effects of this function upon the circulation, and on the blood itself, and consecutively upon the organic and cerebro-spinal nervous systems, also depresses the vital power in a very remarkable manner. Among the causes of primary debility, Dr. Ged- dings has included aneemia. There can be no doubt of the existence of debility, when the blood is deficient or impure ; but, instead of being the cause, anaemia is the effect of debility. 8. ii. Consecutive or Secondary Debil- ity may arise in two ways : (a) from increased excitation of an organ, occasioning proportionate diminution of the energy of others—Sympathetic debility, or Debility from an irregular distribution of the vital endowment; and (6) from the exhaus- tion occasioned by previous excitement.—A. Sym- pathetic Debility (Debilitas Spuria,Huff.land; Metastatic Debility, Dr. Geddings.) When it is considered that the organic or ganglial nerves alone supply the blood-vessels, and the secreting organs and surfaces; that they communicate very freely with each other, and with their chief centre, the semilunar ganglion; that they are formed into numerous plexuses, rendering thereby the con- nection between them still more close; and that they are intimately related to the cerebro-spinal system, through the medium of communicating nerves; the mutual dependence of action betweeu 476 DEBILITY —Complicated. the various organs of the body may be easily explained. If, moreover, it be granted, as I have endeavoured to prove in another work, that the most important vital phenomena, — as di- gestion, assimilation, circulation, secretion, ani- mal heat, generation, &c. — in short, that life itself, with all those manifestations of it now par- ticularised, and which have usually been called organic — result from the influence exerted by the ganglial nervous system, through the instru- mentality, of the vessels and structures, upon the circulating fluid they contain, and reciprocally by this fluid upon the nerves ramified in the parietes of the vessels, and upon the ganglia themselves, through which it must necessarily circulate, — the agency of this system in the pro- duction of the numerous phenomena of debility must be evident. From this view of the sub- ject, and taking into account the various func- tions of dissimilar textures, and, under certain circumstances, the combined influence and re- action of the cerebro-spinal system and sensorium, the numerous relations of disordered actions, as respects the manifestations not merely of debility, but of disease generally, may be more satisfacto- rily traced. 9. When one organ or general system is simply excited, without being otherwise diseased, the functions of other organs, with which it is more or less intimately related by means of the ganglial nerves, undergo a relative degree of change; for as we exalt the vital manifestations in one or more parts of the series, we diminish them in equal pro- portion throughout the remainder. These views were first stated in the London Medical Reposi- tory, for May, 1822, and fully illustrated in my Physiological Notes, published in 1824; and have since been adopted by Boisseau andGEDDiNGS. A due application of them is of the utmost im- portance in pathology and therapeutics, as well as in ascertaining a large proportion of the forms of debility, particularly those presented to us in the course of many acute and chronic diseases : thus irritation of the mucous surface of the sto- mach or bowels enfeebles the rest of the frame; aad inordinate excitation of any other secreting organ diminishes the nutritive and animal func- tions in an equal degree, and so or as respects various other viscera and structures, as more fully explained when describing the states of vital en- ergy connected with the nature of disease. (See art. Disease.) 10. B. The Debility of Exhaustion, or from excitement of a part, or of the body generally (Indirect Debility, of Brown.) —This form of debility arises from all agents, mental or physical, which excite the actions of a part, or of the system, above its normal state. Many of these causes act with great rapidity and intensity, others very slow- ly and insidiously; and whilst some simply change the grade of vital action, others seem to alter it in kind. Their effects vary remarkably with the susceptibility of the organ and constitution on which they act, and the frequency of their repe- tition; each successive application being generally less efficient than the preceding, if it be delayed until the action of the previous one has terminat- ed. The circumstance of stimuli being produc- tive of exhaustion, or indirect depression of vital power, to as great extent below the standard of health, as the previous excitement rises above it, as fully shown by Brown, Darwin and R^h, and that stimuli must be repeated in krgerq«J£ tity to produce the same effects, although present, ing certain exceptions, are important facts, as relpects this pathological condition in Pf™"» and disease in general: as long, also, as tne repe- tition of the stimulus follows so quickly ana leg- ularly as to anticipate the appearance of trie con- secutive debility, the unavoidable consequences ot its abstraction will not appear, at least for a very long time. But they ultimately will supervene in a most severe, and often dangerous, form, when such an event takes place; and if it does not occur soon, the prolonged excitement will ultimately terminate in organic change. Drunkards and opium-eaters often furnish proofs of the latter fact; and persons who indulge in an occasional debauch only, or who undergo great physical or mental exertions, feel the truth of the preceding positions. There is one cause, however, which requires to be particularised on account of its mode of operation and consequences : this is excessive sexual indulgence. It occasions a loss of vital power through the medium of the discharges, in- dependently of the exhaustion consequent upon the previous nervous excitement. Its depressing effects are, moreover, experienced by all the or- gans, but especially in the ganglial and cerebro- spinal nervous systems; and are often followed by the most serious results in both male and female. 11. iii. Complicated Debility. — I have contended, in the article Disease, that the vital manifestations of an organ, or of the frame gener- ally, may be modified, not only in grade, but also in kind. If this be admitted, it follows that debil- ity, originating in either of the ways now shown, may be either simple, or associated with an other- wise morbid state of vital action. Upon a review of practical facts, we shall find that the more sim- ple states of debility most frequently occur either primarily—especially from agents abstracting vital power — or indirectly, from causes which over- excite the nervous influence, or which abstract as well as exhaust vital power; such as the one last adduced. But the condition now under consider- ation is more generally the result of causes which either irritate in a slow and continued manner some particular tissue or viscus, or modify the sensibility of an organ, or change its secreting or nutritive actions, or even vitiate the condition of the circulating fluids. Whilst the preceding forma of debility are mostly met with in the commence- ment of diseases, or constitute the early stages of those ailments consisting almost entirely of simple asthenia, but, which are often mistaken for structural maladies, this condition is observed chiefly in the progress, or towards the close, of many acute and chronic complaints, some of which are of a specific or malignant character; and it may arise out of either of the foregoing varieties of debility, especially when much pro- longed. That which becomes so remarkable in the course of typhus, or yellow fever, of plague, or of syphilis, cancer, scrofula, &c, consists not of a simple depression or exhaustion of vital power merely; for this power is also specifically modi- fied even from the commencement of these dis- eases ; — the sensibility and organic contractility are changed; the secretions and nutrition are in- terrupted, or much affected ; and although the debility may be the same as to grade in several DEBILITY — Special Manifestations and Effects. 477 or all of them at certain of their stages, yet is the vital endowment otherwise modified in each, and in such a manner as to present specific characters whereby they may be severally known and dis- tinguished, without taking the grade of vital mani- festations into the account. It is this form of debility which may be imputed to what has been called, in general terms, by Brera, the evolution of matters injurious to life: and it very often arises from causes, which, by the nature of their im- pression upon the living frame, not merely de- press, but also otherwise vitiate, the conditions of life in all the systems and organs of the body, as shown by the effects produced by the morbid effluvia of typhus, yellow fever, and other malig- nant diseases. 12. II.The special Manifestations and Effects of Debility. — I have hitherto been considering asthenia in its general conditions; I have now to view it in its specific or partial states. In doing this, I shall only attempt an imperfect outline of its relations to the principal general systems and organs of the body, and endeavour to show that one or more of them may manifest this state in a greater degree than the rest, or in a modified form; and that in this manner much of the varied phenomena of disease may arise ; but that neither of them can experience it to a great extent, or for a long time, without either a similar state of disease extending more generally, or some other morbid condition springing out of it, — con- sequences which must necessarily result from the intimate union of the different organs by the or- ganic nervous and vascular systems, as well as from the mutual dependence of their functions, and the reciprocity of vital influence. 13. i. Debility of the general systems. — A. The close connection of the organic or ganglial nervous system with the manifestations of life has been in several places insisted upon ; and con- formably with this opinion, and with intimate views of the origin and nature of morbid actions, debility cannot exist in a marked degree without this system being primarily affected. But of the extent of this affection we can form no estimate, excepting from the effects upon the functions of those organs which it influences. I have long considered, and on various occasions endeavoured to show, that the ganglial and the vascular systems, j by their resulting and reciprocal actions, are the factors of life; and that the part which the former consequently and necessarily performs in the causation and removal of morbid phenomena is most immediate and important. If we examine closely the manner in which causes invade the frame, we shall find, a great proportion of those which produce any of the states of vital depres- I sion already noticed, make their impression in ' such a manner as to leave no doubt of their action being primarily exerted upon this system, ■ thereby proving its very close connection with I life. It is, however, evident that the impression made in this quarter will not remain for any time limited to it; but will extend in the first instance to ! those parts which are most intimately associated I with it, and dependent upon it for the regular per- formance of their functions. This d prion infer- ence is actually demonstrated by observation; for we find the circulating, the digestive, and the as- similative functions, immediately enfeebled by causes which can operate in no other way, and | through no other channel than the nervous system of organic, life. Such of those causes as are of an intense kind, and are most injurious to life,—which modify while they depress its manifestations, — have their impression rapidly propagated through- out this system, and to the structures and organs which it actuates; whilst those of a slighter kind, or slower operation, may exert their effects in parts of it only, or chiefly, and more or less par- tially in other viscera. Viewing this system, therefore, as that upon which the greater number of causes depressing the vital manifestations first exert their action, and consequently as the point whence the depressing effects proceed, I shall briefly consider these effects in each of the prin- cipal functions, organs, and structures. 14. B. The circulating systems and fluids are affected according to the intensity of the depress- ing causes relatively to the energy of the system at the time; and the ultimate results vary with the successive changes that supervene in it, and the associated nervous systems, and secreting and eliminating organs. — (a) In simple debility, the hearth action is languid, or slow; but readily ex- cited by stimuli. If the debility be chronic, the parietes of its cavities may ultimately become wasted or thinned; or even softened, and the cav- ities themselves dilated. In the advanced stages of acute or complicated debility, the heart's ac- tion is generally very quick, soft, weak, small, and unequal or irregular ; and in chronic cases, its substance softened, flaccid, or even dilated.— (6) The arterial vessels lose some portion of their tone; but, excepting in as far as they con- vey the impulse of the heart on the blood, they are not otherwise affected until debility arrives at an advanced stage, or is acute or complicated. When this occurs, arterial action may even be- come very much increased, particularly as re- spects the frequency of the pulsation communi- cated by the heart's contractions, whilst the vital power of the system generally is remarkably depressed. In such cases, the pulsations are broad, open, quick, and very easily compressed; or they are small, weak, soft, and thready. Acute and complicated debility, thus presenting the ap- parent incongruity of great depression of vital power, with morbidly excited vascular action, Is not infrequently observed in the advanced stages of those diseases in which the circulating fluid becomes contaminated by injurious matters in- troduced into it from without, or generated in it, in the manner explained in the article Blood (§ 110— 144.). In these, although the general manifestations of life are enfeebled to the utmost, yet the action of the heart and arterial system is excited by the irritation produced by the con- taminated blood circulating through them, and the low grade of vitality still existing is thereby soon exhausted. — (c) The manifestations of debility on the blood itself, — in occasioning plethora when the vital depression is so slight as not to diminish digestion and assimilation, — in favour- ing irregular distributions, or determination of blood, in its more chronic states, — in producing anamia, when its grade is still lower, or when it is more prolonged, and the assimilative functions, especially affected,—and in giving rise to con- tamination of this fluid, when it impedes the secreting, eliminating, or excreting functions, — will be found discussed in that article. — (d) De- 478 DEBILITY — Manifestations of. in the bility seldom exists long, or in a marked form, i the consequent abundance of fa«y ma ,. •.C.....I • °. .• . .. ■ _.i____1__ -:_...i„.:__~~a ;»= /lonnsition in ine o«h "o impeded circulation or congestions through the veins as one of their more imme- diate effects upon the economy, as shown in the organs, particularly of adipose, cellular, and mug. mate enecis upon me economy, as *>..v,»... ... *..~ , v.6-..~, ,---------j----- , , article Congestion of Blood.—(e) The lym- cular parts is more or less arresteo. phatic and absorbent vessels even escape not 17 C. The vital mantfe^t^oft^re^o. the consequences of debility, particularly when it I spinal nervous system and organs of '™^™r arises from original conformation, or deficient and j be remarkably enfeebled, without tn unwholesome food. This is shown by scrofulous diseases of the glands, in the mesenteric consump- tion of children, and some states of dropsy. (See Lymphatic System.) 15. ii. Debility of the Functions of associated Organs. — The functions about to be particular- ised are depressed by, (a) Causes which lower the vital actions of the foregoing systems in a general and severe manner; and (b) by such as operate immediately upon these organs them- selves. The former, being more general, and more intense in their operation, are immediately followed by arrest, or remarkable disturbance, of frame being materially affected : but they may also be uncommonly active, although all the other functions of the body are debilitated. Idiotcy and certain states of insanity are often met with unconnected with any marked depression of die physical powers; and, on the other hand, partic- ularly in chronic debility attended by emaciation and quickened circulation, the powers of mind are frequently very acute. The slightest change in the freedom, activity, or quickness of the cir- culation in the brain and spinal cord, and in the purity of the blood, will materially affect the character of the pheuomena associated with de- the functions in question; whilst the latter causes < bility of these organs, or of the body generally, usually, but not always, over-excite and there- | As long as the circulation is unimpeded, and the blood sufficiently purified by the emunctories, debility will be attended by great activity of all the senses, and increased irritability of all the muscles. He'nce arise various of its forms, famil- iar to every observer of disease, — that with in- creased sensibility (the Debilitas ad Sensum of some writers,) and that with augmented irritabil- ity (the Irritable Debility of Hufeland and other German authors, — the "Mobility " of Dr. Cull en;) both which forms constitute increased susceptibility, or excitability, of the cerebro-spinal system, and of the organs they influence. When, however, retarded circulation occurs in this sys- tem, or if the blood itself be rendered inappro- priate to its state and functions, by the super- abundance of unassimilated materials, or if it be insufficiently purified by the emunctories, debility, whether thus limited or universal, will be attended by a proportionate degree of torpor (the Torpid Debility of Hufeland,) as well as by adynamia of all the organs dependent upon this system; instances of which are sufficiently common in many acute diseases. In this way the various manifestations of debility in the mental faculties, the general sensibility, and the mobility of the frame, in different cases and complications of disease, may be explained, — particularly if the various organic changes which so often super- vene or become associated with this state of vital power, and with either of the conditions of the cerebral and general circulation now al- luded to, be called into aid. The causes also, the nature of their impression, and their mode of operation, will remarkably modify the state and duration of cerebral asthenia. These are chiefly, (a) Such as act immediately on tliis sys- tem,—as inordinate mental exertions, tlie depres- sing passions and emotions, excessive fatigue, and narcotic poisons, (b) Those which act indi- rectly or mediately, — as the intense or prolonged impression of cold on the surfaces, terrestrial and infectious miasms, the actions of various sedative or contra-stimulant agents, and the abuse of the sexual organs; all which occasion modified or even different effects. The organs of sense, as by exhaust these functions, and, by the frequency of their repetition rather than by their intensity, produce their effects more slowly and partially. Jl. The digestive and secreting organs are amongst the first to experience debility, however induced. This may arise from the evident depen- dence of their functions upon the ganglial system of nerves. But they may be especially affected, and may continue so for some time, without other parts of the frame evincing much disorder, particularly when the debility has been slowly and indirectly produced. The more special man- ifestations of debility in the stomach, the liver, the duodenum, and bowels, usually begin in this way; and they have severally obtained, accord- ing to the forms they assume, the names of in- digestion, torpor of the liver, flatulence, constipa- tion, colic, &c. — these being the more common effects, although several others may be adduced. When debility, either of an acute or chronic form, affects chiefly the digestive organs, the abdominal secretions and excretions are more or less disordered — are usually in smaller quantity and vitiated quality. But this is not the only result; they are generally retained on the surfa- ces and situations where they are secreted, until they undergo various changes, and acquire ir- ritating properties. This is well illustrated by many of the functional diseases of the liver, and bowels. (See Cecum, Colon, Concretions, Constipation, Liver, Worms, &c.) 16. B. The respiratory and assimilating func- tions manifest debility in various ways ; the re- spiratory by frequency, shortness and quickness of action, and diminution of the changes usually produced upon the blood and air respired; the as- similating function by the thin and watery state of the blood, by the deficiency of its quantity, or of its red particles, as in anamia, and, in slighter cases, by the milky or oleaginous condition of the serum. When debility is slight or recent, or when it has been gradually induced by stimulat- ing agents, nutrition is not very materially affect- ed; it may even be partially increased, owing to impeded or imperfect secretion and assimilation, DEBILITY — of the whole Frame. 479 well as other parts immediately controlled by the cerebro-spinal system, have their functions enfeebled and impaired in proportion to the de- bility it experiences. But they may also be individually affected, and in various degrees, without this system being materially disordered. Such occurrences generally arise from the oper- ation of local causes,—as over excitement of the organ, and exhaustion of its sensibility by its peculiar stimuli ; as weakness or loss of sight from over-exertion, or the intense or prolonged action of light; and loss of hearing from great noises, &c. 18. D. The muscular structures, from their connection with the ganglial and cerebro-spinal systems, necessarily experience the effects of de- pression of the energies of these systems, varying, according to its acute and chronic form, its degree, its simple or complicated state, and the progress it has made. But debility seldom originates in, or is limited to, these structures. Its earliest and simplest manifestations in them are diminished tone, flaccidity, wasting, particularly of volun- tary muscles ; lowered, or, in some cases, mor- bidly increased irritability, according as the nerv- ous systems experience a diminution or increase of their susceptibility (§ 17.) ; occasioning, in some cases, irregular and tremulous motions, and a disposition to spasmodic or convulsive action, but more frequently defective energy of contraction, or power of continuing and repeat- ing it, in both the involuntary and voluntary classes of muscles. In the more acute, or the more advanced and complicated states of ady- namia, the insensible tonic contractility of mus- cular fibres are in a great measure lost; their vital cohesion is also so much diminished as to admit of their being more easily torn ; they are incapable of performing even a portion of their functions ; and their contractions are feeble, vi- bratory, or oscillating, productive of the utmost fatigue, sometimes of death ; and the least ex- ertion, even that requisite to preserve the body recumbent upon one side, cannot be sustained for a few minutes. These extreme states of debility occur in the most dangerous and severe cases of disease, as in adynamic fevers, scurvy, &c, and when the circulating and secreted fluids have become sensibly changed from their healthy condition. 19. E. The sexual organs, whilst they par- ticipate in the vital depression of the general systems, are often themselves chiefly affected. It is by no means uncommon to meet with in- stances, particularly in the male sex, of the most complete debility of these organs, amounting sometimes to entire loss of function, from preco- cious and inordinate excitement and indulgence ; there being little or no other disorder, excepting enfeebled mental manifestation, in some cases. In others, however, all the organic and cerebro- spinal functions have become remarkably weak- ened, although not to the extent experienced by the organs in question. (See Impotency.) 20. iii. The Manifestations of Debility in particular Tissues are less evident than in the general systems and associated organs ; and they are later in becoming evident. It is usually not until they are extreme, long-continued, or compli- cated, that they are remarkable.—(a)The cellular tissue at first evinces deficient firmness and elas- ticity, with softness, and, as debility increases, loss of its vital cohesion : it at lsat presents a ten- dency to oedematous or serous infiltration, and even to haemorrhage, owing to weakness of the extreme vessels terminating and originating in it, and the insufficient support it yields them. When it is thus changed, the spread of other diseases through it is thereby remarkably promoted, and an unfavourable termination hastened,—as in cases of diffusive inflammation, erysipelas, punc- tured or poisoned wounds, &c; its vessels having lost their power to limit the extension of inflam- mation by forming coagulable lymph. — (6) Mu- cous membranes are amongst the earliest of the particular tissues to experience the effects of de- bility, thereby increasing and perpetuating many of its phenomena. At first their functions merely are impeded ; their secretions either diminished, or imperfectly excreted, or increased from relax- ation of their vessels, or in other respects viti- ated. As debility, whether of them especially, or of the frame in general, advances, vital cohe- sion becomes impaired, and they yield not the requisite support to their vessels ; whence result softening, haemorrhage from their surface, ecchy- mosis, asthenic ulceration, atrophy, &c. — (c) The serous tissues undergo a partial diminution of their cohesion, and permit an aqueous or serous fluid, in some extreme cases tinged with blood, to escape through their exhaling pores.— (d) The erectile textures at first evince greater susceptibility, particularly when debility has been induced by inordinate excitement of the sexual organs ; but as it increases, they lose their pecu- liar functions.— (e) The fibrous tissue also ex- periences relaxation, becomes less elastic, and more readily yields than in health, giving rise to almost spontaneous dislocations, — results which have occurred in the chronic debility caused by masturbation, as remarked by Sir Astley Coop- er and Mr. Copland Hutchison, and by my- self in one case.—(/) The osseous texture occa- sionally experiences, in children, an imperfect deposition of ossific matter, or even absorption of a great part of that already secreted ; and, in aged persons, the removal of the animal matter which gives due cohesion to this structure : and, (g-) The corneous tissues are often variously changed ; the hair either falling out, or becoming thin, weak, or gray; the epidermis inclined to ex- foliate, and rough or scaly; and the nails thin, long, crooked, or irregular. 21. III. Debility of the whole Frame. —Debility seems, as already stated, most frequent- ly to originate in the ganglial and vascular sys- tems, which I have viewed as the chief factors of life ; the digestive, assimilative, excretory, and cerebro-spinal organs being subsequently affected. But it may also commence in, and continue for a considerable time limited to, either of these, or even, although rarely, to one or more of the in- dividual tissues. When existing thus locally, it usually springs from local and indirect causes, and is at first of a slight grade, the functions of the part merely being impeded ; but, as it continues, the rest of the economy becomes implicated in various degrees, owing to the reciprocity of vital action and function existing throughout the frame. With this universal diffusion of asthenia, the part primarily disordered may still continue affected in a greater degree, exhibiting the changes of func- 480 DEBILITY — Symptoms —Diagnosis. tion, and even of structure, now briefly sketched in respect of the principal systems, organs, and tissues, according as they may be implicated; but, in many instances, the debility becomes co-ordi- nate throughout; and in rare cases, the part orig- inally affected even partially recovers its powers upon some other organ having its vital energies more remarkably depressed. 22. IV. Characteristic Signs, &c.— When asthenia is thus general and fully developed, the external aspect of the body, and all the vital functions, are affected; the extent and specific char- acters of ailment furnishing important pathological as well as therapeutical indications to the practi- tioner:—The countenance is palej thin, or collaps- ed, sometimes bloated and discoloured: the eyes lose their animation, and sink in the sockets, and they are surrounded either by a dark or bluish, or by a tumid and cedematous, circle; the expression of the features is languid and depressed; the lips are pale; the tongue watery, moist, soft, broad, and sometimes tremulous, and the papillae depress- ed and wasted; the voice and speech are weak, or nearly lost; the voluntary muscles lose their pow- ers, and hence, in extreme cases, the continued supine posture, the inability to retain a position on either side, the sinking down in bed, and the falling of the head on the breast or on either shoulder. The surface of the body has its tem- perature diminished, is sometimes partially cover- ed with a cold or clammy perspiration, becomes soft and flabby, occasionally of a more lurid or dirty hue, or pale and waxy, particularly in com- plicated debility; the firmness and elasticity of the soft solids are lost, and they either present a leu- cophlegmatic appearance, or they are remarkably emaciated,—the latter being particularly the case when the circulation is accelerated. The func- tions of the stomach and bowels are impaired, or altogether suppressed; and hence the want of ap- petite, the constipation, and emaciation, — which last effects first the adipose tissue, and next the cellular and least vitalised structures. When the depression is very great, the vital attraction requi- site to the nutrition and healthy cohesion, especial- ly of the more remote and superficial parts, being necessarily diminished, the function of absorption gains the ascendancy; and the less perfectly an- imalised constituents, particularly the adipose sub- stance and the effete elements, are carried back into the circulation; and thus, in some states of disease, the body continues to live upon itself, until the functions are restored, or life extinguish- ed; the external soft solids, attached to, or cover- ing, the bones, meanwhile become remarkably extenuated. In general, the pulse is frequent, soft, small, and easily compressed; the action of the heart is weak, and leipothymia or syncope occur upon exertion, or on quickly assuming the erect posture. Respiration is frequent, imperfect, or anxious or difficult, and the motions of the tho- rax are slight and confined. The functions of the cerebro-spinal system are more or less enfeebled; and, with the changes described above (§ 17.) present the following phenomena : — Loss of memory; inability to prosecute a lengthened chain of discussion, or to fix the attention long on one subject; sometimes weakness, with hebetude of all the faculties; an unpleasant feeling of lan- guor, and exhaustion, with a sense of anxiety re- ferrible to the pracordia and pit of the stomach; vertigo or headach; noises in the ears, either with or without impaired hearing ; weakness ot 1be limbs, and relaxation of the ligaments of the jomta, with tremors, occasionally convulsive movements, or local paralysis; and ultimately low or quiet de, lirium. , „ 23. V. Diagnosis.—A distinction has usually been made between real and spurious debility. The latter term, however, implies a contradiction. But as it is the morbid condition, and not the name imposed upon it, that requires notice, I may briefly allude to it. The state of system, to which this name has been applied, would be better ex- pressed by denominating it oppression of vital power; this, or nearly similar appellations (" op- pressio virium," " debilitas ab oppressione,") having been employed by several modern pathol- ogists? The vital manifestations may be general- ly or partially oppressed by whatever impedes their free reaction in removing the impression pro- duced by injurious agents, or by whatever arrests the function of an important secreting organ, or vital emunctory, whereby the vascular system becomes overloaded, and consequently oppressed throughout, as well as in the organ whose func- tions have been interrupted. The distinction will be more easily understood by a reference to facts. —During pneumonia, the lungs perform their functions in respect of the blood imperfectly, and the various secretions and excretions are diminish- ed. Hence the quantity of the circulating fluid ii increased ; the circulation through the inflamed lung rendered difficult; the functions of this organ impeded, and the vessels generally dis- tended beyond their power of reaction upen their contents, so as to restore the suspended functions. In such cases, the pulse is suppress- ed, and not much accelerated ; but it conveys the sensation of a confined limit of pulsation, thereby suggesting the idea of a sustained state either of tonicity which the systole of the ventri- cle cannot much affect, or of distension upon which the elasticity of the vessel reacts imperfect- ly in the intermissions between the systoles. That this state actually obtains, is shown by the effects of blood-letting hi changing the character of the pulse, in removing the feeling of oppression, and in partly restoring the strength. Inflam- mations of other organs — as the liver, brain, &c. — also furnish instances of oppression of vital power. In all these, however, the state of the surface of the body, and other symptoms above noticed as characterising true debility (§ 22.), do not exist. In fevers, also, the reaction fol- lowing the impression of the exciting causes is very generally attended by oppression of the powers of life, owing, in some cases, to an over- loaded state of the circulation from interrupted secretion, &c; aud, in other cases, partly to this circumstance, and partly to the depressing influence produced by these causes still continu- ing, and, jointly with the increase in the quanti- ty of the circulating fluid, favouring congestion of iuternal secreting and vital organs. Hence, in several forms of these diseases, a complicated pathological state is the result; viz. depressed, followed by oppressed, vital power, as soon as attempts at reaction begin to be made, in or- der to overcome the injurious impressions and changes occasioned by the exciting causes. This suppression of power may arise out of true DEBILITY — Consequences and Terminations — Treatment. 481 debility, may be associated with it, and terminate in it, in its worst and complicated states. 24. The Duration of debility is extremely various. It may, particularly when acquired and slight, be remarkably long, or continue through life, which it may not even abridge. When rapidly and primarily produced, or general and intense, or complicated, it is usually acute as respects its continuance ; but when consecutive, or partial, or the result of irritation of particular textures, it is prolonged into the chronic state; its duration depending greatly upon its degree, and both being extremely various. 25. VI. Pathological Relations.—i. The Consequences and Terminations of debil- ity are, (a) Impeded or interrupted secretion; (b) Changes of the circulating fluids ; (c) Various states of irritation, or inflammatory action, in particular organs or tissues; (d) General reaction of the vascular system, associated with various grades of vital power, from the lowest, or most asthenic, to its highest, or most sthenic form, with their modifications ; (e) Changes in the firmness, elasticity, nutrition, colour, form, and vital co- hesion of the soft solids, and, in some instances, ultimately in the hard solids also ; (/) Effusions of fluids (aqueous, serous, sanguineous, &c.) from mucous or serous surfaces, or in cellular or pa- renchymatous structures ; (g) The production of numerous forms of organic change; (h) The for- mation of new or adventitious tissues or produc- tions, as tubercles, tumours, melanosis, cancer, hydatids, worms, gangrene, &c; and, (i) lastly, Death, which may occur directly from the in- tense action of the depressing cause, but more commonly through the medium of one or more of the changes now enumerated, the first and greater part of which often taking place con- secutively. 26. ii. Associations of Debility.—Asthe- nia is very frequently connected with some other morbid condition, implicating either particular parts, or the system generally. Amongst these are the consequences now enumerated (§ 25.); but the most important are, (a) The association of depressed with otherwise modified or morbid states of the vitality of the system ; (b) with a vitiated condition of the blood and secreted fluids, either or both of which constitute the complicated debility already mentioned (§ 11.); (c) with a disposition to solution of the textures generally, or of a part merely, as in malignant fevers ; (d) with congestions, and chronic or acute inflammations of particular organs or struc- tures, as in complicated forms of fever, erysipelas, diffusive inflammations, dysentery, &c; (c) with intestinal worms, hydatids, and various malignant and adventitious formations. 27. A knowledge of the pathological relations of this most important and singularly overlooked condition of vital power is necessary to the prac- titioner, inasmuch as it enables him to entertain enlarged and connected views of disease, by the aid of which he may the better comprehend such states of disordered action as cannot be readily assigned to any particular type or specific form, owing to their imperfectly marked characters, the associated disturbance of different organs .and structures, and the want of prominent symptoms, whereby they may be ascertained. Debility not only constitutes, in its more intense forms, dis- ease itself, and a most serious part of many of the most dangerous maladies, but it also predis- poses the body to be affected by the numerous in- jurious agents to which it is constantly exposed. • 28. iii. The Predisposition to be affected by (he exciting causes of disease, arising out of debili- ty, will necessarily vary with the form and grade it assumes, and the circumstances in which it has originated. This proposition is too evident to require illustration. But when the debility pro- ceeds from irritation of one or more structures abstracting vital power' from the rest (§ 9.), it may not increase, but may in some cases dimin- ish, predisposition, particularly when it is attend- ed by exalted sensibility and accelerated circula- tion. Thus the debility attending irritation in any part of the respiratory organs even dimin- ishes the disposition to be affected by malaria, and infectious or epidemic agents. So much, however, of what constitutes liability to diseases is owing to the temperament, diathesis, the modes of life, and habit of body, as well as to general or local debility, that the exact share of each can rarely be ascertained. General debility ei- ther in its direct or primary form, or as consecu- tive of over-excitement, disposes the system to be affected by terrestrial emanations, vicissitudes of season and weather, and infectious effluvia. The more local or partial states of debility, par- ticularly when existing in secreting organs and the associated structures, render them liable to congestions, inflammatory irritation, to disordered secretion and excretion, to spasmodic or con- vulsive movements, to effusions, to various states of inflammation, and organic change, with the other consequences and associations of debility above enumerated (§ 25, 26.), upon exposure to causes which disturb the balance of vital mani- festation throughout the frame in a sudden or violent manner, or which impede the assimilating and depuratory functions, and thereby disorder the vascular actions and the circulating fluid. (See Disease— Causes of.) 29. VII. Treatment.—In attempting to re- move debility, our means should be directed with a strict reference to its form, grade, and com- plication. These, however, are so numerous, that precise rules of treatment cannot be laid down; the only attempts of this kind that .can be made, falling more appropriately under those diseases of which depressed vital power forms an essential part. (See especially the First Class of the author's classification.) In the treatment of debility, in either its simple or associated states, there is a particular class of remedies, viz. tonics, which are more beneficial than any other; al- though many articles belonging to other classes, as diffusive stimulants and antispasmodics, may often be prescribed, and with great advantage. Tonics, which have derived their name from their influence in augmenting the tone of con- tractile parts, owe the principal part of their good effects to their elevating, in a gradual manner, depressed vital power, hardly up to, and seldom or never above, the healthy standard ; and to the permanency of their action. By their repeti- tion before the effects of the previous dose have subsided, the beneficial influence ultimately is propagated throughout; and as soon as one or more important functions are restored, the rest participate in the change, and the whole assume 482 DEBILITY—Treatment of Primary. a regular discharge of their offices, owing to the reciprocity of vital influence and function exist- ing throughout the economy. Much, indeed, if not more, is also due to the partial absorption into the circulation of their active constituents ; and to their direct action on the vessels, the dif- ferent tissues, and on the blood itself. Although various diffusive stimulants and antispasmodics produce beneficial effects in several states of debility, yet they are generally-much less service- able than tonics, and in many instances are even injurious, chiefly from the quickness and little permanency of their action, from their proneness to over-excite and over-heat the system, and consequently to indirectly depress its energies. Hence, in order to perpetuate their restorative effects, it becomes requisite to repeat them more frequently; and thus a habit and desire of ex- citation is generated, which, if not gratified, is followed by insupportable exhaustion. Howev- er, in many states of disease, they are beneficial from the rapidity of their action, and are useful adjuncts to more appropriate means. As all the agents which restore the vital energies vary not only in the grade, the rapidity, and the per- manency of their action, but also in respect of the organ, or the system, or tissue, on which their influence is chiefly exerted, it becomes a most important object in practice to ascertain the part primarily and chiefly affected, and to pre- scribe them according to our knowledge of their mode of operation. 30. Before adopting measures to remove de- bility, we should ascertain, 1st, The causes in which it has originated ; 2dly, Whether or no it may not be apparent merely,—the consequence of oppressed, and not of depressed, vital power ; 3dly, If it proceed or not, from irritation of a par- ticular part, abstracting the due energy from oth- ers ; 3dly, Whether it be simple or complicated; and, 4thly, If it be associated with any local mis- chief or change of structure. Having ascertained these important points, the next object is the choice of agents, and appropriation of them to the states of debility presumed to exist. It is chiefly to the neglect of a pathological analysis similar to the above, of the cases which occur in practice, that the abuse of tonics in diseases of debility is chiefly to be attributed. 31. i. Primary Debility should be treated, con- formably with the injunction now given, with strict reference to its cause, to the particular form it has assumed, and the organs or parts chiefly affected. If it have arisen from abstrac- tion of the stimuli necessary to health, these should be restored ; if from depressing agents, whether physical or moral, these should be coun- teracted as far as may be. — (a) When debility is manifested more especially in the viscera im- mediately influenced by the ganglial and vascular systems, it very generally proceeds from one or other of these classes of causes ; and, besides their removal or counteraction, requires, accord- ing to the rapidity and the intensity of their opera- tion, the most carefully selected remedies. If the vital depression be rapidly progressive or very great, diffusive stimuli, as camphor, ammonia, j the aethers, serpentaria, arnica, &c, will be re- quisite in the first instance, until it is arrested, when tonics will be more serviceable ; but, with ! the first indication of reaction, stimuli of every ! kind should be laid aside, lest the consequent excitement should be carried to an inordinate height by their means. The propriety of pre- scribing tonics appropriately to the states and grades of debility, as insisted on by Hoffmann and Thomann, cannot be doubted; but opinions will differ widely as to those which are more suitable to certain conditions. When the vital depression affects the action of the heart more particularly, after momentarily exciting the ol- factory and respiratory nerves, as well as those of the stomach, by means of the volatile and diffusive stimulants, as the aethers, ammonia, and aromatic spirits, &c, the more permanent tonics should be employed. If there appear to be a deficiency of blood in cases of this description, the preparations of iron will be most serviceable, aud will be advantageously combined with myrrh, cinchona, gentian, willow bark, casca- rilla, and the sub-carbonate of potassa. If the organic nervous influence be depressed, without any manifest deficiency of blood, either of these vegetable tonics may be taken, with the fixed alkalies or their sub-carbonates, or with the mineral acids, according as it may be desirable to promote the secretions, or to impart tone to the extreme vessels. When we wish to excite the functions of the viscera generally, and par- ticularly when the blood does not undergo the requisite changes as it circulates through the different assimilating and depuratory organs, the chlorates of potass and soda (the oxymu- riates) will be found of much use. I have employed them for several years with much benefit, at the Infirmary for Children, m dis- eases of debility affecting chiefly these organs, as well as the preparations of iodine, especial- ly the hydriodate of potass. The bitter tonics, combined with aperients, will also prove of great service in similar cases. The marked advantages of associating individual medicines from each of these two classes, — first made known to me by the writings of Hoffmann, and confirmed by repeated observation, — are brought about both by their increasing the action of the se- creting and excreting viscera when thus con- joined, and by their improving thereby the con- dition of the circulating fluids, as well as per- manently exciting the vital influence. In some cases, the combination of small doses of the ex- tract of nux vomica, or of strychnine, with aloes and myrrh, has proved equally beneficial. It was in pathological states similar to those now under conside(ation, that phosphorus was pre- scribed by Conradi and others, that the inhala- tion of oxygen gas was strenuously advised by Beddoes, and that electricity and galvanism were generally recommended by Continental writers. But I perfectly agree with Grapen- geisser, in viewing these as calculated to be injurious where there exists any increase of irri- tability, either locally or generally, or where any vital organ is congested. 32. When debility is the consequence of the injurious impression of some powerful agent, as terrestrial or infectious effluvia, it will often be most advantageous to interrupt the succession of morbid phenomena by the exhibition of the most active tonics in large doses, and in conjunction with warm cordials. All the more intense states of primary debility proceed from impressions DEBILITY—Treatment of Consecutive. 483 made by sedative causes upon the ganglial sys- tem, and may be removed by counter-agents directed to the same system, before consecutive changes have advanced far, or the functions of the emunctories and the state of the circulat- ing fluid have been disordered to the extent of giving rise to the early phenomena of febrile reaction. Thus, the more stimulating emetics, immediately followed by powerful tonics, or ca- thartics preceded by or combined with warm tonics, will often prevent the accession of fevers, when exhibited before the cold stage, or rigor, has commenced; and, in some cases, although it have commenced, if it have not terminated in excitement. But, in these cases, the tonics and other excitants prescribed should be of such kind, and in such quantity, as will make a power- ful impression on the nervous system of organic life, and as are calculated to restore the sus- pended secretions. The preparations of cincho- na, or the sulphate of quinine, combined with the hot spices, as capsicum, or with camphor, or with ammonia, and prescribed in large doses after an emetic, and followed by a purgative conjoined with the same stimulants, are the most eligible in such cases. The preparations of ar- senic, the sulphates of zinc and iron, piperine, the muriate of ammonia, the chlorates, and va- rious other tonics, are also appropriate in cases of primary debility, especially when assisted by the cardiacs now mentioned ; but they are less efficient than the foregoing in removing the vital depression primarily induced by the exciting causes of fevers. 33. When asthenia affects especially the capil- lary vessels, and the crasis of the blood is de- ficient, or when haemorrhages take place unat- tended by vascular excitement, the more astrin- gent tonics should be given with sulphuric acid; and if the loss of tone be excessive, these should be associated with cardiacs and aromatics, and alternated with moderate or full doses of the more energetic terebinthinates, and balsams; morbid secretions being duly evacuated by the prepara- tions of rhubarb. 34. (b) Debility manifested chiefly in the associated organs of digestion, can never be per- manently removed, unless the secretions and ex- cretions be duly promoted; and, for this purpose, the combination of tonics and aperients alluded to above is the most efficacious. But this prac- tice should not be resorted to whilst irritation, or active congestion of, or determination of blood to, any of these viscera exists, lest we thereby con- vert such disorder into inflammatory action. In such circumstances, the more heating tonics, or those which contain most of resinous or oleaginous constituents, are the least appropriate. Where irritation of the digestive mucous surface is com- plicated with debility of these organs, mild tonic infusions may, notwithstanding, be exhibited with benefit, especially those of calumba, gentian, cin- chona, quassia, &c; and may be combined with acids, or with small or moderate doses of the nitrate of potass, or the sub-carbonates of potass or of soda, or with both the nitrate and sub-car- bonate. It is chiefly in cases of this description that diffusive stimuli and heating tonics, so much and justly inveighed against by Broussais, Otto, and Philips, are injurious. When asthenia is associated with a somewhat lax state of the bowels, not proceeding from inflammatory irri- tation of their mucous surface, muriate of lime, or cusparia, calumba, quassia, or cascarilla, with the alkaline sub-carbonates, &c.,are generally of service. When the debility of these organs is attended by torpor of the liver, or accumulations of bile in the gall-bladder and hepatic ducts deob- struent purgatives should precede the exhibition of tonics and stomachics. If it be associated with worms, purgatives, and afterwards chaly- beate tonics, are required. 35. ii. Treatment of Consecutive or secondary Debility. — A. It will generally be found, when the debility arises from irritation of some organ or secreting surface, that tonics or stimulants, unless such as are mild, and contain but little of an essential oil or other heating constituents, combined with deobstruents and anodynes, will prove either of no service, or injurious, from favouring the supervention of inflammatory ac- tion and organic change. Similar effects are also apt to follow the exhibition of tonics, when de- bility is attended with congestion of some inter- nal viscus or obstruction of secreting organs : and they will seldom be of any benefit until these affections are in some measure removed; unless the powers of life are incapable of them- selves of restoring the tone of the circulation and the suspended secretions, by developing a healthy reaction. In such cases, local depletions, and remedies calculated to excite secretion and excre- tion, should precede, or even in some instances accompany, the exhibition of gentle tonics, which ought to be prescribed in conjunction with de- obstruents, assisted by a change of air and a light nutritious and farinaceous diet. 36. B. The debility which follows over-excite- ment, or which consists of exhaustion of power, requires means proportionate to its degree and form. The most intense grade of exhaustion oc- curs in the last stages of adynamic or malignant fevers, and of some other acute diseases; and often demands not merely permanent excitants, but the more active stimuli, as camphor, ammonia, serpen- taria, arnica, wine, spirits, aethers, &c, to prevent the rapid extinction of life: whilst other states of exhaustion, especially such as are slower in their accession, or follow local inflammations, spas- modic or haemorrhagic diseases, and the less se- vere forms of fever, admit only of the more gen- tle tonics ; and even these, particularly if they be not cautiously prescribed, may reproduce the disease wliich occasioned the debility, especially if it was inflammatory or haemorrhagic. It is not uncommon to find acute inflammations re- kindled, or chronic inflammations follow the acute ; and relapses of fevers, or visceral en- gorgements, or obstructions, supervene, when the exhaustion hag been treated by heating tonics or stimulants, or by a premature use of a too full or stimulating diet. On the other hand, too strict exemption from all restorative means has been not infrequently followed by permanent general or local debility, or by very slow recovery; and it has often favoured the accession of other acute or chronic diseases; exhaustion predisposing the system to be impressed by their exciting causes. In the more difficult and doubtful circumstances of this form of debility, it will be, upon the whole, judicious to trust chiefly to wholesome air and suitable diet; and, if tonics or stimulants are 484 DEBILITY — Treatment of Complicated and of Local. necessary, to select those which are the least heating, and to exhibit them along, or alternately, with such medicines as will promote the secre- tions and excretions most requiring aid, and with internal and external derivatives from the princi- pal seat of disease. In cases of this description, particularly in the young, and in those who previously enjoyed a sound constitution, the returning energies of life generally stand but little in need of a spur ; they require rather a judicious guidance, especially in respect of the digestive, the secreting, and excreting func- tions. 37. iii. Complicated Debility, or that condition of the frame which consists not merely of a de- pressed, but of an otherwise morbid state of vital power, has been ascribed above—1st, to un- wholesome food, and to imperfect assimilation ; 2dly, to an impure or altered state of the cir- culating fluid, occasioned by impeded or disor- dered secretion and excretion ; and, 3dly, to the absorption of morbid matters into the blood, either from some one of the mucous surfaces, or from parts of the body in which they have been generated. The operation and effects of these sources of contamination have been fully insisted on in the articles Absorption, and Blood (§ 110 — 151.). The indications of removing them may be resolved into the following : — 1st, To cut off" the supply fiom the sources of contam- ination ; 2d, Te raise the powers of life, as ex- pressed chiefly in the ganglial and circulating systems, by the means pointed out under that head (§31.); 3d, To promote the depuratory actions of the emunctories. 38. A. The propriety of endeavouring to ac- complish the first of these intentions cannot be questioned; but, when the contaminating matters are formed in some part of the system, as in various malignant diseases, apparently local at their commencement, it frequently cannot be put in practice, or the period at which it might have been attempted with any prospect of success may have passed, and the other intentions are our only resort. — B. The second indication is to be fulfilled by the remedies already noticed (§ 31.), and the treatment recommended in the article Blood (§ 157.) ; particularly by the al- kaline chlorates ; the preparations of bark, of iodine, of iron, of arsenic, or fjf zinc ; by astrin- gents and antiseptics, as the acetic and citric acids, &c.; by the preparations of the bitter roots and woods, or of the aromatic and tonic barks, with liquor potassa, or the alkaline sub-carbo- nates, in the more chronic diseases, and with the sulphuric, the muriatic, or nitric acids, in the more acute maladies, and with warm spices, &c.; and by the gum-resins, the balsams, the terebin- thinates and camphor, prescribed according to the circumstances of the case. C. But whilst we are endeavouring to elevate vital energy by those and other means, we should also fulfil the third intention, by associating, or alternating, them with the more tonic and stomachic purgatives, or with warm and stimulating diaphoretics, as the abdo- minal or the cutaneous secretions may require to be promoted. 39. iv. Debility affecting chiefly associated or- gans, or particular textures, requires nearly sim- ilar means to those already advised, according to the grade and form it may assume. The treat- ment of its manifestations in the ganglial and vascular systems, and in the digestive viscera, has been already noticed; and is still more partic- ularly discussed in the articles Blooq, Color, Indigestion, &c—A. Debility of the cerebre- spinal organs must be treated according to the causes that have occasioned it, and the characters it presents. The causes, whether moral or phy- sical, should be removed or counteracted as far as possible; and if it have arisen from mental ex- citement, repose and agreeable amusement should be inculcated, (a) When it is characterised by- increased sensibility, the bitter infusions with liquor potassae or the sub-carbonates of soda or potash, with conium or hyoscyamus; the prepar- ations of iron; chalybeates; vegetable tonics and aromatics, with small doses of opium or the pre- parations of morphine ; cold or shower baths ; sea-bathing, change of air, &c, mental tranquil- lity, and agreeable employment; are amongst the most efficacious means, (b) If it be attended by increased irritability or mobility, the mineral acids, alone or with bitter infusions; the prepara- tions of cinchona; the acetic acid; Hoffmann's anodyne, valerian, assafcetida, musk, or vegeta- ble tonics, with opiates or anodynes, the prussic acid, the Iceland moss, ass-milk, alkaline or tepid baths, &c, are suitable remedies, (c) If the de- bility be great, and particularly if it be attended by torpor or depression of the sensibility depend- ing neither upon cerebral congestion, nor upon a plethoric state of the vascular system, the warm or diffusible stimulants, combined with permanent tonics ; aromatics and cardiacs ; iodine, strych- nine, or the extract of nux vomica in small doses; coffee; camphor or phosphorus in minute quanti- ties; warm salt water bathing; the shower bath ; chlorine fumigating baths; the use of astringent and camphorated washes to the head and surface of the body ; the nitro-muriatic acid bath, or sponging the surface of the trunk, or even the head itself, with a tepid wash containing these acids, may be tried and associated with the fore- going, or other internal remedies, according to the peculiarities of the case. 40. B. The sexual organs are debilitated—(a) from imperfect developement, depending upon their interrupted evolution, or upon general as- thenia; and (o) from over-excitement. The first of these causes seldom occurs in the male, but not infrequently in the female (See Chlorosis, and Menstruation,) and in such cases requires the constitutional treatment there described. The second cause is common to both sexes, although perhaps more so in the male than female. When it has thus originated, and exists merely in a slight degree, without amounting to impotency, the or- gans will recover their energies soon after mar- riage, if regular and abstemious habits be adopted. In other circumstances, and in severer cases, at- tention should be paid to the general health : the mind ought to be occupied by interesting pur- suits; the patient should rise early in the morning, .and use the shower bath, or local aspersion or affu- sion, aud live regularly. If the causes in which it originated be relinquished, the sexual function will soon be restored. The tonics which are the most efficacious in cases of this description are, the muriated tincture of iron, taken in the infusion of quassia, or of chamomile flowers; the tincture of iodine ; coffee ; and the extract of conium, DEBILITY —Treatment. 485 with the preparations of cinchona, cascarilla, or iron, &c. (See Impotency and Sterility.) 41. C. The manifestations of debility in the cellular, the mucous, and other tissues, must be treated according to the principles already stated. When asthenia in any of its various forms affects the digestive mucous surface, the treatment al- ready noticed (§ 34.) is applicable. If it be at- tended by haematemesis, malaena, or intestinal haemorrhage, the terebinthinates, and sulphuric acid, either alone or with tonic decoctions, or the superacetate of lead with acetic acid and opium, are the most energetic. If it manifest itself chiefly in the respiratory mucous membrane, the astrin- gent tonics, the mineral or vegetable acids, the inhalation of the fumes of astringent and tonic substances (see Bronchi, § 100.), sponging the chest daily with tepid or cold astringent lotions, change of air, sea-voyaging, and horse exercise, are amongst the most salutary measures. 42. v. Of the various constitutional and local diseases with which debility is commonly associat- ed (§ 25,26.), little or no mention need be made at this place, as they are particularly noticed else- wliere. I may, however, remark that inflamma- tions occurring in a debilitated and cachectic state of the frame, more especially if the debility be of that complicated kind described above (§11.), are characterised by deficient energy of all the func- tions actuated by the organic nervous system, and by imperfect tone of the vascular and capillary system itself (see Inflammations — Asthenic Forms of;) and that they seldom admit of the large depletions which are indispensable in the healthy or sthenic states of those diseases. The inflammations which not infrequently supervene in the course of adynamic fevers, and certain forms of erysipelas, as well as various other asso- ciations of the pathological conditions now under consideration, fully illustrate this position. Such asthenic forms of complicated disease, however greatly increased the general vascular action at- tending them may be, require the powers of life to be supported, and, in many cases, powerful tonics and stimulants to be exhibited, even at the time that it may be necessary to resort to local or. derivative bleedings in order to prevent the disor- ganization of the viscus especially affected. In all such maladies, the pulse is remarkably quick, often full, but soft and compressible—a state which, although resulting from depressed vital energy, is too generally viewed as evincing a very different condition; and depletions, often the very cause of the great frequency of the pulse, are resorted to, in order to render it slower — to perform an im- possibility : the important pathological facts, that great quickness of pulse is the consequence of de- bility, and that the most tumultuous and morbidly increased vascular action is very frequently asso- ciated with the utmost depression of vital power, being either unknown or overlooked. 43. vii. The treatment of the debility attending convalescence from disease has been partly an- ticipated, particularly at § 36.; but I may here offer a few additional remarks on this important subject.—a. The great susceptibility of the system to impressions from external agents or mental emotions, attending the debility of the early stage of convalescence, should make the practitioner cautious as to its management. Exposure to cold, the premature exhibition of stimulants or of too 38 heating tonics, to great indulgence of the appe- tite, and inappropriate food, may occasion re- lapses, may favor the supervention of other dis- eases, and may thereby superinduce dangerous or irremediable organic change. This is no infre- quent occurrence after fevers, particularly the exanthematous, and after inflammations of the viscera. Such unfavourable results proceed not merely from the above causes, but also from in- attention to the secretions and excretions ; the patient often relinquishing too soon the use of those means which are still requisite to enable the weak powers of life to perform their various func- tions. The laying aside the use of medicines too soon is even still more frequently productive of mischief in convalescence from chronic diseases, particularly those of the bowels and liver, and dropsies. In these, the use even of the same means that removed the complaint is often neces- sary for a considerable time afterwards, either in different doses or in modified forms. During the whole period of recovery, the causes which pro- duced the malady ought to be carefully avoided; and the physician should prescribe the diet and regimen of the patient, and such other measures as may seem to him calculated to ensure the object proposed. The articles of diet should at first be bland, digestible, and in small quantity, which may afterwards be gradually increased ; and, with the returning powers, the farinaceous food first adopted may be added to weak animal decoctions,—or to milk, particularly asses' milk. Subsequently white fish, boiled; or chicken, rab- bit, game, or the lean of well-fed mutton, may be taken, at first in small quantity and without heat- ing condiments. Although white fish or flesh may not be more readily digested than game, venison, or mutton, yet they are generally not so heating as the last-mentioned article, or as beef. Before wine, or any other exciting beverage, be allowed, the effects of the gentle and tonic bitters, in the form of infusion, should be first observed; and if these occasion no febrile excitement, nor accelerate the pulse, a little old wine, particularly Hermitage, sherry, or East India Madeira, may be taken in water with the principal meal. 44. b. The temperature of the room, and the bed and body clothing of the patient, ought to be duly regulated according to his habits, and the peculiar- ities of the case, and with strict regard to ven- tilation. Subsequently, change of air and suitable exercise should be prescribed; at first in a close or open carriage, according to the season, and afterwards on foot, or on horseback; the last of which, and sea-voyaging, being the best suited to convalescents from pulmonary diseases. 45. vii. Moral Regimen, and other means.— A. There are various other remedies that may be resorted to in the more urgent cases of debility; but these are pointed out in the articles on the specific diseases, of which debility forms an im- portant part.—a. The internal use of tar water, once so inordinately lauded, and subsequently so very undeservedly neglected, and medicated baths, may, however, be here noticed. I have had several opportunities of observing the good effects of a course of tar water, or of an infusion or de- coction of pine tops and shoots, in simple debility, and in complaints chiefly to be referred to this state of vital endowment.—6. The idea that the skin is entirely incapable of absorbing fluids in 486 DEGLUTITION, DIFFICULT. which it may be immersed, has led to the neglect of medicated baths. But it should be recollected that, independently of any power of absorption this structure may possess,—and which I believe it possesses under some circumstances, and in re- spect of various agents,—it is a living, an active, a finely sensible, and, as to the nature and extent of its functions, an important organ; and that it is very susceptible of impressions by which not only its own functions are modified or altogether chang- ed, but the actions of other organs are variously affected in consequence of the nervous and vas- cular connections and functional relations, which bind the different parts of the economy into one indivisible whole. Entertaining such views, I be- lieve that cold, tepid, warm, or medicated baths; that lotions or washes, or stimulating liniments and frictions applied to the surface, — the former in slighter cases, the latter in the more urgent; are not infrequently beneficial in diseases of de- bility, when judiciously employed, and with due reference to antecedent or existing visceral disor- der. Sea or salt water bathing; shower baths; camphor and chalybeate baths; warm, tepid, or cold baths, either general or local, of iodine, or of iodine and sub-carbonate of potassa; baths of decoctions of willow or oak bark, sometimes with the addition of an alkaline sub-carbonate; washes with camphor water, rose water, and vinegar, applied to the trunk; or sponging the surface daily with a mixture of these, at a temperature of about 60°; or with a small proportion of the nitric and muriatic acids in water at a temperature of 70° to 80°; are respectively of much service, when suitably prescribed. 46. B. Moral treatment, or attention to such mental impressions and emotions as are cal- culated to promote the physical means resorted to, is particularly beneficial in restoring the vital powers, especially when the nervous systems manifest a more than ordinary share of depres- sion and its attendant disorders. The manner and bearing of the physician, when calculated to inspire confidence, will of themselves do much in fulfilling the intentions of his prescriptions. The faith reposed in the remedies resorted to will often accomplish as much as they are physically capa- ble of performing, and not infrequently much more. In order to inspire this feeling, the phy- sician should himself evince a calm, and, in cases of great danger and depression of the vital ener- gies, a cheerful confidence. Hope, in whatever form it may be excited, and in every degree to which it can be elevated, is a most powerful agent in combatmg diseases of debility; whilst its opposite, despondency, — the consequence and j the cause of debility,—is one of the greatest evils we have to guard against in these maladies. Every practitioner whose range of observation has comprised the malignant diseases of warm climates, or of temperate countries, must have remarked, that when the patient dreads, and still i more if he entertains a sentiment of, an unfavour- able issue, or if he be apathetic and careless of the event, the very worst sign of depressed vital power has appeared, and the most active moral and physical stimulants are then required; whilst, on the other hand, a firm confidence in the phy- sician, and ardent desire of recovery, are the best aids by which his endeavours can be seconded. 47. C. Travelling,—owing to the exercise, the change of air, the continued succession of novel and exciting objects presented to the senses, the agreeable occupation, without exhaustion of the mind which attends it, and the amusing and ex- hilarating matters incidental to it,—is one of the most efficacious means of restoring the depressed or exhausted powers of the frame, especially the enfeebled functions of the digestive organs and of the nervous system; and nearly allied to it, are pleasant society, rational amusements, and varied, interesting, but not fatiguing, bodily and mental employments. Bibliog. a\d Refer.—Celsus, 1. iii. cai>. 4.—Aretaus, Curat. Acut. 1. ii. c. 3. (Human and ass milk:)—dvicenna, Canon. I. i. fen. 2. doct. 2. cap. 29.—Albert i. De Atonia, Hals, 1716.—Hoffmann, De Morbis ex Debilitate Fibrarum oriundis. Lugd. Bat. 1737. — Buchner, De Debilitate Part. Co p. Solid, ad imminuta earum Cohesione pendente. Hal. 1749.—Ludwig, De nimia Animi Defatigatione, Causa De- bilitat's in Morbis. Lips. 1762.; et De Debil. Corporum Curalionem impediente. Lips. 1758.—Vogel, Defin. Gen- erum Morb. Goet. 8vo. 1764.—Sauvages, Nosologia Me- thodic*, vol. i. p. 699. Ainst. 1768. — Calduni, Instilut. Pathologic. &c. 8vo. Berl. 1776. — Withers, Observat. on Chronic Weakness. York, 1777. 8vo.—Lentin, Beytrage, p. 81. (Chalybeate baths.)—J. Brunonis, Elementa Med- icina?. Edin. 1780.; and his Works, by his Son, 8vo. passim. — Saunders, in Edin. Med. Comment, vol. iii.— Nicolai, De Debil. Vera et Spuria. Jens, 1791.— Wide- mann, Diss. Sistens Vitia Genus Humanum Hodiernum De- bilitantia. Jena?. 1792.—Haase, De Debil. Vera et Spuria. Lips. 1792.—Wedekind, De Debil. Mixta. Heidelb. 1797.— Darwin, Zoonomia, or Laws of Organic Life, 8vo. 1797. — White, Observat. and Experiments on the Willow Bark. Bath, 1798. — Fieliz, in Richter's Chirurg. Biblioth. b. vi. p. 717. (The willow baric.) — Hill, On the Use of Oxygen, or Vital Air, in the Cure o: Diseases. Lond. 1800. — Hei- necken, Ideen, &c. p. 76. (The marriage of the old with the young.)—Ploucquet, De Rite Formanda Indicatione Antasthenica. Tub. 1799.—Marcard, Beschreibung von Pyrmont, b. ii. p.22. (ThePyrmont waters recommended.) —Horn, Beitrage zur Medicin. Klinik, b. ii. p. 293. (Specifies four grades^—Thomann, Annates Wurced. &c. b. i. p. 43. (The propriety of distinguishing the forms, and appropriating the remedies.) — Marcus, Priifung des Brown-Systems, b. i. st. 4. p. 37. (The greater the debility, the more penetrating and volatile excitants.)—Schreyer, in Baldinger's N. Mag. b. viii. p. 546. (Baths of decoction of bark.)—Grapengeisser, Versuche, &c. p. 96.—Beddots, On the Med. Use, &c. of Factitious Airs. Bristol, 1796, 8vo.— Conradi, in Hufelund's Journ. der Pract. Heilk. b. vi. p. 385. — Otto, De Remediorum Incitantium Abusu. Franc. 1804. — WWfAer, Disquisitio Rationis Morb ad Statum Corp. Asthenicum. Jena, 1801.—W. Vogt, De Pareseos et Methodi Paretica? Dignitate. Viteb. 1805. — Brera, Annotazioni, &c. vol. ii. — Graefe, in Horn's Archiv. Sept. 1810, p. 169. (Chalybeate baths).—Mylius, Hufeland und Himly, Journ. der Pract. Heilk, Nov. 1809. p. 24. (Decoc- ' tion of raw coffee.)—Jaeger, Ueber die Natur. u. Behand- lung der Krankhaften Schwache des Menschlichen Orgna- ismus. Stutt. 1807. — C. Sprengel, Institutions Medics, vol. iii. p. 90. Amit. 1813. —P. C. Hartmann, Theoria Morbi, seu Pathol. Generalis, &c. 8vo. Vind. 1814.— Harles, Handbuch der Aerztlichen Klinik, b. i. p. 250. — Shearman, On Hist, and Treat, of Chronic Debility, &c. 8vo. Lond. 1824. —Fan Coetsem, Medicina; Theoreticae Con- spectus, 8vo. Gand. 1825, p. 81. — L. H. FriecUander, Fundamenta Doctrina? Pathologies, 8vo. Lips. 1828, p. 98. —Roisseau, art. Asthinie, in Diction. Abregi des Sciences M6dica1es.—J. C. Roche, in Diet, de Med. et Chir. Prat.b. in. p. 593.—Brachet, Mumoire sur l'Aslh^nie, 8vo. Paris, 1829.—Hufeland, Encyclopad. Worterhuch der Medicin. Wissen. b. i. p. 453.—Geddings, On the Pathological States denominated Asthenia, Debility, &c, in Amer. Journ. of Med. Sciences, vol. ix. p. 315.—(See also the Bibliography and References of the art. Disease, and the art. Debil- itas, in Ploucquet's Medicina Digesta, vol. i.) DEGLUTITION, DIFFICULT. — Syn. Dys- phagia (from dvc, difficulty, and tpu/o., / eat or swallow). Deglutitio diffidlis vel impedita, Auct Schweres Schlingen, Ger. Dysphagie, Fr. Dysphagy. Difficulty of Swallowing. Classif.—1. Class, Diseases of the Diges- tive Function ; 1. Order, Affecting the Alimentary Canal (Good). Special DEGLUTITION, DIFFICULT —its Pathology. 487 and General Pathology ; Symp- I tomatology. (Author, Sec). 1. Difficult or obstructed deglutition is an oc- casional symptom of several diseases, and a con- stant concomitant of a great variety of organic changes, affecting the fauces, the pharynx, the cesophagus, or parts in their immediate vicinity ; and which are discussed under these heads, par- ticularly in the article on the OEsophagus. After having noticed the only idiopathic form in which dysphagy can strictly be said to occur, I shall arrange those pathological states of which it is an important phenomenon, and with reference to the places in which they are more appropriately de- scribed, and to the principles and means of cure. I. Primary or Idiopathic Dysphagy. Nervous Ouinsey, Heberden. Classif.—II. Class, I. Order (Au- thor). 2. Defin.'—Difficulty of swallowing, occur- ring suddenly, and accompanied by a choking sensation. 3. i. This form of dysphagy is not infrequently observed. It generally takes place when the pa- tient is apparently in good health; and chieflv in irritable, nervous, or weak constitutions. It is usually induced by violent gusts of temper, or men- tal emotions, or by dread of its accession ; and is occasionally so severe as to threaten suffocation. When it affects the cesophagus, it gives rise to a sensation resembling that occasioned by the reten- tion of an extraneous body ; and matters attempt- ed to be swallowed are either retained for some time, or rejected. When the pharynx is princi- pally affected, deglutition is generally attended by a sense of choking. It may continue only for a minute or two, or it may be prolonged for sever- al days, or even months, difficulty being present in various degrees upon each attempt at receiv- ing substances into the stomach ; or it may be remittent. It is often accompanied by the re- tention of flatus in the cesophagus, probably by spasm ; the difficulty of deglutition being increas- i ed by the flatulent distention, but removed upon the discharge of flatus. It resembles in this the globus hystericus ; but it differs from hysteria in i the circumstance of its occurrence in males as well as in females, and independently of any of the other characteristic symptoms of that affection, j 4. ii. The Treatment of primary or idiopa- thic dysphagy should be directed with the view, 1st, of relieving the existing difficulty ; and, 2dly, j of preventing its recurrence.—(a) The first object may be attained by swallowing slowly cold or iced fluids ; by cold applications to the neck or throat; | by cathartic, anodyne, and antispasmodic enema- ta ; and by camphorated liniments, or antispas- | modic and anodyne plasters placed on the sternum or throat, (b) The recurrence of the affection will be prevented by the internal use of vegetable bitters and tonics, with the alkaline sub-carbon- ates ; by narcotics or antispasmodics combined with ipecacuanha ; and by a free action kept up for some time on the lower bowels, by means of the resinous or other purgatives conjoined with vegetable bitters, and promoted by clysters. The other means, mentioned hereafter (§ 16.) will also prove useful adjuvants. II. Symptomatic and complicated Dys- phagy. Classif.—General Pathology ; Therapeutics, &c. 5. Difficult or obstructed deglutition is an occa- sional or constant attendant upon a variety of func- tional disorders, and of organic changes. 1st. It is often symptomatic of hysterical, hypochondriacal, flatulent, and asthmatic affections. 2d. It is con- stantly attendant upon tetanus and rabidity. 3d. It is sometimes produced by organic change seat- ed in parts about the base of the brain or cra- nium, the medulla oblongata, or upper part of the spinal cord. In all these symptomatic states, the parts immediately concerned in the function of deglutition are seldom, and not necessarily, affected organically ; but in the following there always exists either inflammatory action, or its consequences, or some structural change, in the parts by which food is conveyed into the stomach, or in their immediate vicinity. The preceding may be called symptomatic forms of dysphagy ; those which are to follow, complicated states of this affection. Under this latter may be arrang- ed, 1st, Dysphagy from congenital malformations ; 2dly, From inflammation, or structural lesions of the mouth, tongue, fauces, pharynx, or tonsils ; 3dly, From diseases of the epiglottis or larynx ; 4thly, From inflammations or structural lesions of the cesophagus, or of the cardiac orifice of the stomach; 5thly,From tumours pressing upon the pharynx, or on the cesophagus. On each of these I shall add but few remarks. 6. i. Symptomatic or Sympathetic Dys- phagy.—A. Of spasmodic or flatulent diseases. Dilficulty of swallowing occasioned by hysteria, hypochondriasis, spasmodic asthma, dyspepsia, and even rabidity, is in a great measure to be ascribed to a flatulent distension of a portion of the cesophagus, with spasmodic constriction of other parts of this tube, and disposition to convul- sive or spasmodic action of the muscles of the pharynx, either upon certain occasions of their being excited by the mind, as in hydrophobia, or upon attempts at performing their usual functions. In many instances, particularly those connected with asthma, indigestion, or flatulence of the di- gestive canal, the difficulty is attributable rather to the ascent of flatus in the oesophagus, prevent- ing the transmission of food into the stomach than to spasmodic action of the muscular parts con- cerned in the process. In these cases, the pa- tient feels much pain, with a sense of distension or pressure under the sternum, and in the course of the cesophagus after swallowing. 7. A. Dysphagy may be occasioned by struc- tural lesion about the base of the brain or cervical portion of the spinal cord, or about the base of the cranium. In such cases, the paralysis may be more or less complete ; and it may be limit- ed to the muscles of the pharynx and upper part of the oesophagus (Bonet, Portal, Bald- in ger, and myself), or it may have extended to them from other parts. Numerous cases illus- trating these positions have been recorded. The participation of the muscles of deglutition in either general or partial paralysis is very com- monly observed in apoplexy, &c.; and the occur- rence of this form of dysphagy, independently of organic change, or rather from congestion about the base of the brain, is shown by its occasional accession in the advanced stages of fevers. Paralysis of the muscles concerned in this function rimy also be produced by wounds of the nerves of the face (Palletti), by light- 488 DEGLUTITION, DIFFICULT — Diagnosis. ning (Paterson), and by severe cold (Bleu- land). It is, however, most frequendy caused by the slow developement of tumours, or cysts, or other structural changes about the base of the cranium, whereby either the nerves supplying these muscles are compressed at their origin or in their course, or a portion of the brain or of the upper part of the spinal cord is injured. 8. ii. Complicated Dysphagy, or difficult deglutition from structural change affecting the parts immediately concerned in this function, comprises a great variety of lesions. I shall merely enumerate them with reference to their seat; their nature, morbid relations, and treat- ment, being fully discussed under more appropri- ate heads. 9. A. Dysphagy from congenital malforma- tion. — Extreme smallness or enlargement of the tongue; the termination of the pharynx, or of the oesophagus, in a cul de sac, or obliteration of the cesophagus ; the division of this part into two canals, and its communication with the tra- chea ; are the chief malformations which interrupt deglutition ; and are of very rare occurrence in otherwise well-formed infants. Cases, however, have been recorded by Blaes, Van Cuych, Michel, Billard, Martin, A. Cooper, and Andral. In these, death, necessarily resulting from inanition, took place in from three to nine days. A slight interruption to deglutition very frequently arises from congenital fissures of the soft and hard palates. 10. B. From diseases of the mouth and throat. — (a) Inflammation or chronic enlargement of the tongue ; ranula ; sublingual calculus (Guen- ther); and aphthae, ulceration, tumours, and ex- crescences about the base of the organ (Reid- lin, Van Swieten, Tode, andlNGLis); are not infrequent causes of dysphagy. Cases of chronic enlargement of the tongue, impeding de- glutition, unconnected with malignant disease, and continuing for many years, are recorded by sev- eral writers. I have seen an instance of this kind, that had existed from infancy to nearly middle age. These and other affections, with the treat- ment appropriate to them, are particularly no- ticed in the article upon the Diseases of, and the Indications furnished by, the Tongue. — (b) The fauces and tonsils not uncommonly occasion dysphagy. Inflammation, suppuration, ulcera- tion, or destruction of the soft palate, or of the uvula; great relaxation of the latter part; in- flammation, abscess, chronic enlargement, and ulceration, of the tonsils; fungous and other tumours and polypi of the maxillary sinus, or posterior nares ; various tumours or excrescences attached to the palate or tonsils (Schmidt, Thi- lenius, &c.) ; and the severe effects of mer- cury, or the sudden arrest of salivation ; are gen- erally attended by more or less of dysphagy. — (c) When the pharynx is the seat of inflamma- tion or of its consequences, or of the lesions now enumerated, or of malignant disease (Kergara- DEc,and myself), deglutition is commonly much more impeded than when only the fauces are affected ; and in some instances it is extremely difficult or nearly impossible. In such cases, the epiglottis and larynx are more or less irritated, and, by the consequent disorder of the respiratory actions, the dysphagy is still further increased. Foreign, and particularly pointed or sharp, bodies I lodged in the pharynx, are also sometimes causes of dysphagy. 11. C. Dysphagy from disease of the eptglot- 1 tis and larynx.—(a) Inflammation, ulceration, l and entire destruction of the epiglottis, or indu- ration, incurvation, and the removal of it by wounds, will occasion difficult deglutition, as in the cases recorded by Mayn waring, Schurig, Bonet, Desgranges, Tonanni, and Lar- rey. (b) Also inflammation and ulceration of the larynx, ossification of its ligaments, and dis- placement of the os hyoides, are generally attended ; by dysphagy. The possibility of the occurrence of this last cause, although observed by Valsal- va, and Mollinelli, has been doubted; but the instance of it noticed by Sir C. Bell (Surg. I Observ. p. 160.), and the case wherein it was caused by swallowing a large hard substance, recorded by Dr. Mugna (Annali Univers. di. Med. Nov. 182S.), put the matter at rest.! frac- ture of this bone by external violence has pro- duced not only an impossibility of deglutition, but even more serious consequences, as shown in the , cases published by Dr. Marcinkowski and M. Lalesqde (Journ. Hebdom, fyc). — (See La- rynx— Diseases of.) 12. D. Diseases oftheatsophagus, and cardiac orifice of the stomach, will impede or altogether obstruct deglutition. Inflammations and their con- sequences, as softening and ulceration, induration, thickening, stricture, and purulent collections between the coats of these parts ; also partial dilatations, sacs and diverticula, or even large pouches, either with or without thickening and stricture of the part of the cesophagus immediately below the dilatation (Blasius, Haller, Mec- i kel, Monro, Ludlow, C. Bell, Odier); polypous or fungous excrescences or tumours of various kinds in some portion of this canal, or in 1 the cardiac orifice of the stomach ; or scrofulous, callous, cartilaginous, osseous, carcinomatous, or scirrhous degeneration of these parts ; or merely I enlargement or ulceration of their mucous glands; and spasm, rupture, or perforation of the oeso- phagus, or the lodgment of foreign bodies in it; are severally causes of dysphagy ; and are fully : described in the articles on the Pathological | Anatomy of the Digestive Canal ; and on j the Diseases of the CEsophagus, as well as in those of the Stomach. 13. E. Tumours pressing upon the pharynx, , or upon the asophagus, —as bronchocele, or oth- | er tumours or abscesses near the throat and in the neck ; tumefaction of the lymphatic and secre- ting glands below the jaw, and at the top of the j sternum ; aneurism of the subclavian or carotid arteries, or of the aorta before it passes into the ! abdomen ; enlarged bronchial glands, tumours of | various kinds, and abscesses in the posterior me- | diastinum ; exostoses or other diseases of the cer- vical vertebrae, and purulent collections between them and the cesophagus (Carmichael, myself, and others) ; also abscesses formed between, or involving, the trachea and cesophagus (Hay and myself) ; dropsy of the pericardium (Bang) ;and enlargement of the liver ; have severally been ob- served to occasion dysphagy. 14. iii. The Diagnosis of dysphagy requires a few observations merely.—(a) In idiopathic, as well as in the sympathetic dysphagy, the difficulty takes place suddenly, disappears as suddenly, re- DEGLUTITION, DIFFICULT —Treatment. 489 mils or intermits, and is generally attended either by convulsive efforts, by choking sensations, or by flatulence, dyspepsy, or various nervous symp- toms, particularly when it is connected with hys- teria, hypochondriasis, &c.—(6) In cases of atonic or paralytic dysphagy, solids are more easily swallowed than liquids ; but the process is often very slow, and the difficulty great—(c) When it proceeds from disease of the fauces, the cause is obvious to the sight; and frequently also when it is induced by the state of the pharynx. In this latter case, as well as in dysphagy from lesions of the epiglottis and larynx, or from tumours or fungous excrescences developed in, or pressing upon, the pharynx, or from inflammatory diseases of it, or of the upper part of the cesophagus, sub- stances are often forcibly ejected into or through the nostrils, upon attempts at deglutition, owing to the spasmodic action of the muscles of the pharynx. — (d) When dysphagy is caused by a diminution of the canal of the asophagus, either from thickening of its parietes, or from tumours pressing upon it, &c, difficulty of swallowing solids is first felt, and this at last is followed by a difficulty of swallowing fluids ; the interruption to this function proceeding gradually and slowly. When the obstruction is seated low in this tube or about the cardiac orifice of the stomach, pain is usually felt under the sternum after swallowing : and the matters are afterwards regurgitated into the mouth, owing either to a sudden reaction of the parietes of the canal, or more commonly to their inverted peristaltic action. (See art. CEso- phagus—Diseases of.) 15. iv. Treatment.—It must be evident that the treatment of sympathetic and complicated dysphagy should be conducted strictly according to the pathological state on which it depends, as far as that may be ascertained. Hence a tolerable knowledge of the means applicable to it, in every circumstance in which it presents itself, is to be acquired only by a reference to the articles where the various lesions occasioning it are described, in respect of their nature and cure. 16. A. Sympathetic dysphagy—(a) of spas- modic or flatulent disorders, requires very nearly the same treatment as already recommended in the idiopathic form of the disease. If it accom- pany hysteria, swallowing, slowly, cold or iced fluids, and cold applications to the neck, will soon afford relief; but it will afterwards be necessary to have recourse to tonics and cooling aperients, with other means suited to the peculiarities of the case. The instances in which Tode and Wich- mann found quassia so beneficial, were probably of this kind, or the idiophatie form already no- ticed. — (6) When dysphagy is connected with flatulent dysphagy, or with asthma, or palpita- tions of the heart, relief will generally be obtained from anodynes or antispasmodics combined with refrigerants, or from vegetable tonics with alkaline sub-carbonates and aperients. Blisters, or rube- facient plasters, or either of the ammoniacal, the compound galbanum, or the cummin plasters, with opium or the extract of belladonna, applied over the sternum or throat, will also materially assist the internal remedies. Heinecken advises the preparations of zinc, which, as well as the oxide of bismuth, may be tried in this form of dysphagy. He also recommends the distilled water of the laurocerasus, for which the hydrocyanic acid may be substituted with advantage. Besides these, the cuprum ammoniatum, the preparations of camphor with those of henbane or conium, may also be exhibited. In every form of dysphagia not depending upon organic change, purgatives, and cathartic and antispasmodic enemata, will be productive of more or less benefit. 17. (c) Dysphagy from paralysis or atony of the muscles of deglutition should be treated accord- ing to the principles stated in the article Palsy. If it be occasioned by congestion about the base of the brain or .spinal cord, general or local bleed- ings, active cathartics, and external derivatives, must be employed. Congestion having been re- moved, large doses of camphor, as advised by Hoffmann ; stimulating linctuses and gargels ; sialagogues ; electricity and galvanism ; exciting liniments or blisters to the neck or throat, as suggested by Loeffi.er ; as well as moxas and issues; may be severally employed. Dr. Barton recommends the zanthoxylum in cases of this de- scription. Thunberg and Baldinger advise the cajeput oil to be rubbed on the neck ; Gar- danne, sinapisms to be applied on the same part; and Franck, the actual cautery. 18. B. Dysphagy from organic change of the parts directly concerned in the function of deglu- tition requires means the most diversified, accord- ing to the nature of the lesions to which it is attributable. — (a) When it is congenital, but little can be done excepting in the slighter forms occasioned by cleft palate, or by .adhesion of parts within the mouth. In these, the expert surgeon may afford complete relief.—(6) Difficult deglu- tition from diseases of the tongue, fauces, tonsils, or larynx, is of itself of minor importance; but as respects the primary lesion, of the utmost moment, requiring the most energetic measures pointed out in their treatment. (See these articles.)— (c) Dysphagy from inflammations, or their usual con- sequences, whether seated in the pharynx, the asophagus, or the cardiac orifice of the stomach, should be treated according to the sthenic or as- thenic form they may assume. After general or local depletions, especially cupping between the shoulders or over the sternum, emollient, cooling, and febrifuge linctuses ought to be taken at short intervals. I have prescribed, with advantage in such cases, especially when ulceration has been suspected to exist, linctuses containing the nitrate of potash, or the muriate of ammonia, or the sub- borate of soda, or the sub-carbonates of the fixed alkalies with the nitrate of potash and ipecacuanha, in addition to the other means described in the articles on the diseases of these organs. When foreign bodies are lodged in the pharynx or oeso- phagus, appropriate measures should be resorted to, either for extracting them, or for pushing them onwards into the stomach.—(d) When dysphagy is occasioned by tumours developed in, or press- ing upon, the asophagus or cardia, it is not always that their nature, or even their existence, can be fully ascertained. If their presence be inferred, or when they are developed in external parts, or if the diathesis be scrofulous, then iodine may be prescribed internally as well as externally, with potash, conium, &c. * If abscesses have * I was consulted, in 1826, in the case of a young lady born in India, but who had resided some years in London. The glands in the neck, and underneath the sternal ends of the clavicle and sterno-mastoid muscles as well as in various 490 DELIRIUM. formed between the upper part of the oesophagus and cervical vertebrae, or between the former and the trachea, or about the pharynx, an unfavoura- ble issue might possibly be averted by incisions made into them. If aneurisms press upon the gullet, the treatment recommended when discuss- ing Diseases of the Arteries should be put in practice. — (e) When thickening of the parietes of a portion of the cesophagus, with more or less of stricture or scirrhus of this canal, or of the cardia of the stomach, is the cause of dysphagy, cupping, or leeches applied oven the sternum ; issues and moxas in the same situation, or in each side of the neck ; the linctuses recommended above (§ 18. c); mercurial and other alteratives, with conium, hyoscyamus, camphor, &c. ; the iodide of mercury, or the hydriodate of potash, internally and externally; the sub-carbonates of the alkalies, or the liquor potassae in emollients, &c, with various other means noticed in the article i ontheOZsopHAGis, may be employed. If these fail, a careful trial may be made of the bougie ; but the utmost attention should be paid not only to the manner of using it, but to the effects pro- duced by it; for if the stricture be connected with sacs, pouches, or diverticula, or hernia of the inner coats through the muscular, or even with simple ulceration,—changes which not infrequently take place in the part immediately above the strictures —much mischief may result from even a cautious introduction of a bougie. The frequent and ob- vious connection of dysphagy with scrofula shows the propriety of prescribing the medicines found most serviceable in that disease, particularly when occurring in the scrofulous diathesis : and in such cases, the muriate of lime or of barytes, conium, Uquor potassae, and especially the preparations of iodine, should be fully tried. 19. C. The treatment advised by the best writers on this and its related affections consists of much that has been now stated ; in addition to which, however, I may briefly add, that, the muriate of baryta has been recommended by Kf.rksig ; cold and iced fluids, by Tode and Montat; conium, by Wichmann, Coli.omb, Hufeland, and Johnston ; hyoscyamus, by Withering ; opi- ates, by Ferrein and Conradi ; the liquor potasses, by Haller ; emetics, by Fkrrein ; and local bleedings, by France and Bang: Calomel and some other preparations of mercury have been prescribed by Seq,uira, Stevenson, Engelhard, Brandis, and others,—to the ex- tent of producing salivation, by Kramp, Munck- ley, Brisbane, and Faro.uharson —in the form of mercurial ointment, either alone or with the volatile liniment, rubbed over the sternum and throat, by Dobson, Patten, Kerksk., and Wathen — internally, with antimony, bv Van Ge v n—and with aloes and camphor, by Ha l l e r , Patten, Bang, and Brandis, who contend strenuously for the occasional origin of dysphagy in suppressed rheumatism and repelled eruptions, other parts of the body), were so greatly enlarged as to im- pede deglutition and respiration. She had been treated hv several eminent practitioners; but the tumours had increased. In consultation with Mr. Annesley, who had requested me to see her, a course of iodine was recommended ; and the hydriodate of potash was employed, chiefly internally, for eight or nine months, with occasional intervals not exceeding a fortnight ecch. The glaudular enlargements gradually subsided, the catamenia appeared, and she perfectly re-. covered. She is now well, and married. and also recommend external derivatives and ir- ritants, as sinapisms, issues, setons, blisters, re- peated or kept open, &c. The surgical measures to be resorted to in various circumstances ot the disease are fully discussed in the writings of J. Hunter (Trans, of a Soc. for the Imp. of Med. and Chirurg. Knowledge, vol. i. art. 10.), Df.sault (Surgical Works, Src), Richter (Chirurg. Biblioth. b. xii. p. ll.)> C. Bell (Surgical Observ. cy-c.),andS. Cooper (Surgi- cal Dictionary, cy-c). 20. D. The diet should be chiefly farinaceous, excepting in the nervous and spasmodic forms of the disease; and it ought always to be easy of di- gestion, and taken without any heating condiments. All substances which irritate or excite by their direct or indirect action, are injurious. The stomach also should never be loaded ; and, in every circumstance, the secretions and excretions ought to be carefully regulated and promoted by gentle and appropriate means. Bibliog. and Refer.—Fernelii, Opera Pathol. Lugd. Bat 1645, p. 204. - Ettmutler, Opera Medica, vol. i. p. 37. — Reidlin, Lin. Med. 1696, p. 67. (Hysteria.) —Schurig, Chylologia, p. 257. (Ulcerated epiglottis.)—Morgagni, De Sed. et Caus. Mi rb. epist. xvii. 19. 20. 25., xviii. 22., xxviii. 10.—Lientaud, Hist. Anatom. ."Med. 1. ii. ob«. E04.—Mayn- waring, Med. Facts and Observat. vol. i. — Paterson, in Ibid. vol. viii. art. 6.—Haase, DeCausis DifT. Deglutitionis. Goet. 1781.—Sandifurt, Mus. Anatom. vol. ii. tab. 107. et seq.—Giinther, in Med. Wochenblatt. 1783. p. 555.—Man- get, Biblioth. Pract. l.-iv. p. 860.—Van Swieten, Comment. ad §728.— Haller, Opuscul. Pathol, obs. 78. — Bleuland, Observ. Anatomico Medicae de Sana et Morbosa (Esophagi Structura. Lugd. Bat. 1785.—Engelhart, De Dysphagia. Lund. 1796. — Bang, in Act. Re;. Soc Med. Havn. vol. i. p. 246., et vol. iv. p. 170.—Tode, in Ibid. p. 182.—Portal, Cours d'Anatomie Med. t. iv. p. 535.— Thilenius. Med. und Chirurg. Bemerkungen, b. i. p 47.—Stevenson, in Med. and Phvs. Journ. Lond. Julv, 1802.—Johnston, in Mem. of Me'd. Soc. of Lond. vol. ii. art. 17.—Collomb, Medic. Chir. Werke, obs. 10. — Wichmann. Ideen zur Diagnostik, b. iii. p. 176.—Withering, Edin. Med. Comment, vol. xvi. p. 262. — Farquharson, in Mem. of Med. Soc. of Lond. vol. ii. p. 357. — Wathtn, in Ibid. vol. i. p. 286. — Sequira, in Med. Obs. and Inquir. vol. vi. j>. 138. —Palletti, Nuovo Giorn. della piu Recent. Lit. Medico-Chir. t. vi. p. 163.—Berger, in Act. Helvet. vol. vii. art. 6.(Hysteria.)—Ludlow, iu Med. Obs. and Inquir. vol. iii. p. 85.—Dobson, in Ibid. vol. vi.— Brisbane, Select Cases, p. 77.—Baldinger, N. Magazin, b. viii. p. 175., etb. xvi. p. 162.—Thunberg, De Oleo Cajeputi. I'psal. 1797. —Schaffer, in Hufeland und Himly's Journ. der Pract. Heilk. Feb. 1810. p. 117.—Krauss, in Ibid. Oct. 1811, p. 116.— Heinecken, in Ibid. Mav, 1811, p. 104.— Michailis, in Ibid. Feb. 1812, p. 53.—Franck, Act. Ins(it. Clin. Vilnensis, vol. iii. p. 86.—Patten, in Auserl Abhandl. fur Pract. Aerzte, b. xiii. p. 396. — Desgranges, in Journ. de Med. Contin. t. iv. p. 130. — Conradi, in Arnemann's Magazin, b. i. p. 78.—Lecheverel, in Journ. Gener. de Mid.. t. xxii. p. 135.—Double, in Ibid. t. xxiii. p. 339.—Tonanni, in Atti di Siena, vol. iii. p. 232. — Lxirrcy, Relat. de l'Ex- pedit. en Egypte, sect. viii. Hopfengaertner, in Hufeland's Journ. der Pract. Arzneyk. b. vi. p. 558.—Schmidt, in Hufeland's Journ. der Pract. Heilk. b. xxii. st. 2. p. 64.— Kerksig, in Ibid. b. viii. st. 4. p. 194. — Hufeland, in Ibid. b. ix. st. 3. p. 86.— Inglis, iu Edin. Med. and Surg. Journ. vol. i. p. 34.—C. Bell, Surg. Observ. p. 80.—Meckel, Man. d'Anatomie, t. iii. p. 377. — Curmichael, in Trans, of Irish College of Phys. vol. iii. p. 170.— Monro, Morbid Anatomy of the Human'Gullet, &c. 2d ed. p. 212. — Hay, Trans, of Med.-Chir. Soc. of Edin. vol. i. p. 243. — Kergaradec, in Archives Gener. de Med. t. xii. p. 126. — Bright, Medical Reports, &c. vol. ii. part ii. p. 460. (Hysteric.) DELIRIUM.—Syn. Paraphrosyne, Paraphronia (from nitoa. erroneously, and fpooifV., I under- stand), Auct. var. Paracope, Swediaur. Irver- eden, Aberwitz, Germ. Delire, Fr Delirio Ital. Classif.—Pathology ; Symptomatology. 1. Delirium has been defined:—Disorder of the intellectual powers, with or without derangement of the moral sentiments. But this definition is DELIRIUM — Phenomena. 491 too extended and vague, and embraces the whole circle of mental diseases. J. Franck, and some other pathologists, have restricted it by adding — this disorder assuming an acute form. Several writers, retaining the preceding extended defini- tion, have divided delirium into the acute, and the chronic ; the former consisting of various morbid states of the brain, attended by mental disturb- ance and fever — the latter of mental alienation, unattended by fever or active bodily disorder. Chronic delirium, therefore, comprises all those states of disordered mental manifestation treated of in the article Insanity. Acute, or febrile delirium refers to those morbid affections of mind supervening in the course of febrile, inflammatory, and some chronic diseases, and which have been denominated symptomatic, or sympathetic delir- ium ; and those which are produced by acute diseases, or injuries of the brain or its membranes, and by intoxicating or narcotic substances ; and which have been termed idiopathic delirium by some writers. The common acceptation of the word delirium, and that in which it has been used by the best authors, accords with the acute form as occurring in the manner now stated ; and in this light I shall also view it. But it is more doubtful in how far it is ever an idiopathic af- fection. Indeed, in many of the diseases in which it is admitted by all to be a symptomatic or sym- pathetic disorder, its more immediate dependence upon a morbid state of vital endowment and cir- culation in the encephalon is as manifest as in some of those which have been viewed as idio- pathic. The distinction, therefore, cannot be maintained, especially as it appears to have been founded upon a mistaken idea, viz. upon the sup- posed existence, in the reputedly idiopathic form, of inflammatory irritation or action of the brain or its membranes ; which action does not obtain in the other. That delirium is most frequently occasioned by such a pathological state, cannot be doubted; but it is equally certain that it some- times also proceeds from a different condition; and that either of them — either inflammatory action, or simple disturbance of the cerebral functions without inflammation — may exist in each of the divisions thus distinguished,—in the idiopathic, as well as in the sympathetic form. If the distinc- tion in question be still retained, it would be more accordant with the generally admitted acceptation of the word idiopathic, to consider, as J. Franck has done, all the manifestations of delirium as symptomatic, excepting when it is occasioned by intoxicating and narcotic substances: but, when it proceeds from inflammation of the brain or its membranes, whether primarily or consecutively induced, to view it merely as a symptom, but by no means a constant, although a very general symptom, of this state of disease. 2. Delirium, as well as other cerebral affec- tions, has been too generally imputed to inflam- matory action ; and the state of the ganglial or organic nervous power, which evidently influen- ces both the functions and the circulation of the brain, has been entirely overlooked, particularly as respects this affection. There can be no doubt of the difficulty of appreciating correctly the na- ture or extent of the disorder which this part of the system experiences. But this circumstance surely does not preclude us from tracing ultimate phenomena to their true origin, instead of stop- ping at intermediate effects ; nor from inferring, from the nature of these phenomena, and of the causes which increase or remove them—from the juvantia and Icedantia — certain general con- clusions respecting the condition of that power whence morbid conditions primarily emanate ; each successive effect being the cause of further change, until organic lesion, and ultimately death, result. Believing, therefore, on physiological grounds, that delirium is often the consequence of changes in the state of organic nervous power — of the functions of that part of the organic or ganglial system supplying the encephalic organs — influencing, in some cases, one or more of the mental manifestations, without any appreciable change of vascular action or of structure; in oth- ers, both function and circulation ; and in many, not only function and circulation, but organization also ; and that our knowledge of these changes, of their signs, and of their various related circum- stances, are too imperfect to enable us to come to accurate conclusions ; but that we should pro- ceed nevertheless with the aid of the dawn of knowledge now opening upon us ; I shall briefly consider, first, the phenomena and diagnosis of delirium—afterwards, its pathology and treatment conformably to the doctrine now alluded to. 3. i. Phenomena.—A. The invasion of deliri- um is generally preceded by sleeplessness, head- ach, vertigo, heaviness of the head, noises in the ears, change of voice, absence of mind, forget- fulness of pain, by an air of surprise, and acute- ness of the senses ; the eyes are brilliant, and in- tolerant of light; the head is often hot, the face flushed, aud the circulation of the brain more or less increased. In some cases, however, these symptoms are either altogether absent, or inappre- ciable; and in others the countenance is collapsed, pale, and cool, and the eyes sunk. To the fore- going phenomena succeed those which consti- tute delirium, and which vary remarkably in I character and intensity. In many cases, particu- larly when there are few or no signs of augmented determination of blood to the head, a simple agi- tation or merely absence of the mind, or reverie, or wandering from the objects before it, or a slight - incoherence in the ideas, is all that is observed ; but, from this slight state of affection, we meet with every grade and form of mental disorder — sometimes with fright, visions or illusions, often [ connected with present objects; occasionally with hallucinations, or the reproduction, in confused or unconnected forms, of previous impressions; — in certain cases, with the most furious mental and ; physical agitation; in others, with the greatest de- pression and the most sombre taciturnity; — in one case, with tears and signs of great mental distress; in another, with a lively but incongruous current of ideas, or even with laughter and gayety. 4. B. Delirium is frequently present at first only during the intermediate states between sleeping and waking, which patients in acute diseases ex- perience ; the mind still perceiving objects,, but imperfectly. In this state the patient appears to dream aloud; and when fully awakened, returns I rational answers to questions put to him ; but he soon lapses into a state of dreamy incoherence, or I into that of more complete delirium. This con- : dition nearly approaches that of coma vigil, into which it often passes. In some instances, this • state is characterised by a loss of recollection of 492 DELIRIUM —Diagnosis. all objects observed, and of all ideas with which the mind had been stored during the greater period of life, and by the recovery of the memory of languages and of ideas acquired at a very early age, and long forgotten. Thus old persons, when delirious, although their minds are blanks as re- spects every thing present, or which have become known to them from youth or manhood, will talk of matters which had interested them previ- ously to such periods, and sometimes in a lan- guage which they had then spoken, but of which objects and language they had no recollection long before their delirium, nor retained any after their recovery. Here, again, the remarkable si- milarity between several manifestations of de- lirium and dreams is strongly evinced; the ob- jects and ideas about which the unconscious mind is engaged in the states of both delirium and dreaming being frequently those which had made a vivid impression in youth, which had become erased by the cares aud employments of life, but which are recalled during certain conditions of the brain. The production of these in incongruous forms, and the giving utterance to the morbid conceptions formed of them, constitute halluci- nations; whilst, owing to the nearly inconscious state of the mind, the imperfect and erroneous impressions made by surrounding objects on the senses of the patient, give rise to inconclusive and unconnected conceptions, in consequence of the morbid condition of the brain, and occasion the illusions characterising the delirious affection. 5. In addition to disorder of the mental powers, the organs of locomotion are remarkably affected. In the low or quiet delirium, and in the less dan- gerous states, in which the brain is only function- ally deranged, the muscles are either somewhat agitated, or very much enfeebled, and the voice is very weak or nearly lost. In more severe cases, the voice and the muscular force are greatly increased ; the patient, however, sinking into a state of profound collapse after a few violent ef- forts. In the most dangerous form of delirium, particularly when it proceeds from organic disease of the brain or its membranes, it is attended, but more frequently followed, by general convulsions, by spastic contractions of one or more of the vol- untary muscles, by entire loss of consciousness and sensibility, or by paralysis. 6. C. Delirium, as M. Georget has remarked, may be continued or intermittent, even in the continued affections of the brain. When it is intermittent, it usually returns with the exacerba- tion of fever that takes place in the evening and night. When the patient recovers his reason, he is generally weak and exhausted; his senses are readily and painfully impressed by their respec- tive stimuli; and he complains of thirst, and pains of the head and limbs. If the delirium has been slight, and consciousness has not been entirely abolished, he retains more or less recollection of what had passed during its continuance. But when it has been intense, or of some duration, he has no knowledge of what has occurred. The epidemic appearance of delirium mentioned by Quelmalz (De Epidem. Mentis Alienatione. Lips. 1752.) and Michaelis (Med. Pract. Biblioth. b. i. st. 1.) is to be imputed to the pre- valence of those diseases in which delirium is apt to supervene, and especially in that form on which it is most frequently an attendant. The duration of the paroxysm of intermittent de- lirium varies from one to several hours ; but the continued form, particularly when occasioned by disease within the head, may last several days, or even many weeks. Sometimes, as in the more severe cerebral cases, it alternates with profound coma. When it terminates fatally, it generally passes into coma ; but in some instan- ces the patient recovers his reason for a few hours before dissolution. 7. ii. Diagnosis. — It is of the utmost im- portance that delirium should not be mistaken for insanity, and especially that the delirious patient should not be removed to an asylum for the insane. On two occasions I have seen such a mistake made, and about to be acted upon, when my opinion was requested. But these cases recovered perfectly: to one of them — a professional man — the removal to an asylum, or the supposition even of being insane, might have been ruinous. There can be no doubt that delirium often passes into insanity, especially when it has been caused by inflammatory states of the brain, and by fevers with determination to the part; or when it occurs in persons heredi- tarily predisposed to insanity; but until it has assumed the features of that form of mental dis- order, it certainly in no respect should be viewed and treated as such. 8. The causes and circumstances originating delirium are often of themselves sufficient to show its difference from insanity. Its occur- rence in the advanced stages of acute diseases, or of chronic maladies when the powers of life have become exhausted and febrile action of an acute kind has supervened, is especially char- acteristic of delirium. The insane patient has all his senses, as well as his digestive, assimila- tive, and locomotive powers, but little or not at all impaired. His mental faculties and intelli- gence are also but partially deranged. M. Gf.or- get has very justly remarked that the mental disorder of the insane is often confined to a single faculty; and even in the most extended, or maniacal affections, the faculties are rather perverted, or insulated, and without the bond of association, rather than extinguished. The most maniacally insane person wills and reasons, and is not always absurd in his actions. But in the delirious, all the cerebral functions are severely affected. His sensations are imperfect and in- correct, his ideas unconnected, his passions disordered, his voluntary motions irregular, fee- ble, and defective ; his intelligence and recollec- tion nearly abolished ; and he is impassive to all that surrounds him. Whilst the delirious patient presents many of the physical signs of exhausted vital energy, or of the gravest state of disease, the insane has all the appearances of unimpaired health, particularly in the early stages of insanity, and before consecutive organic change has taken place. In the former, the sensations and per- ceptions are more or less abolished; in the latter, they are but little or not at all impaired, — the judgment only, or conviction of the under- standing respecting them, being erroneous. The false conviction of the insane is too strong to be removed by the evidence of the senses: the sensations and perceptions of the delirious are always too weak, even when consciousness is partially present, to become the basis of sound DELIRIUM —its Pathology. 493 conclusions. Hence the insane person cannot be convinced by objects seen, heard, and understood by him, in opposition to his perverted judgment respecting them ; and the delirious patient per- ceives objects so faintly, if he perceives them at all, as to be unable to distinguish between such as are in any respect similar, or to recognise one person from another. Besides the circumstance, also, of delirium being generally an acute, and insanity a chronic affection, it may be remarked, that in the former, when occurring from inflam- matory states of the encephalon, or from fevers complicated with such states, the return to the healthy function is often so slow as to occasion fears of the supervention of ihe latter. In some instances, however, the restoration from febrile delirium has been quick, and the mental mani- festations have become even more active than previously to the seizure. 9. iii. Pathology. — It is of the utmost prac- tical importance to distinguish the different forms of delirium, particularly in respect of the grade of vascular excitement and vital power, and the existence or non-existence of inflammatory ac- tion, for, without such a step is previously taken, no rational method of cure can be adopted. I shall therefore attempt to make this distinc- tion. 10. A. Delirium attended by exhausted ner- vous and vital influence is sometimes occasioned by excessive haemorrhages or venisection, by inanition, prolonged lactation, and profuse semi- nal or other discharges, by old age, hysteria, fear, &c. It also occasionally supervenes from exhaustion in the last stages of some acute and phronic diseases, or from whatever directly or indirectly depresses the powers of life, as shown in the article Debility. In many such cases, however, although the vital energies are sunk, | yet tlie brain is more or less excited relatively to the other parts of the body; and in some, the state of delirium is connected with an impure or contaminated condition of the circulating fluids, particularly when it occurs in the advanced course of malignant diseases. The delirium, also, which is caused by excessive pain, by capital operations, by the suppression of the ap- pearances of pain or suffering, or by the appre- hension of the consequences of operations, and which M. Dupuyiren has very appropriately denominated nervous delirium, chiefly falls un- der this form of the affection ; and to it may be added many of the instances of delirium caused by excessive irritation in remote but related orgaas or parts, as consumption, ulcerations of the bowels, worms, &c. Although it is often obvious that a relatively increased determination of blood to the head exists in some cases of this form of delirium, yet it may be inferred, with equal justice, that a deficient supply of blood to the brain obtains in others. This conclusion may be legitimately drawn from the pale, cool, shrunk features, sunk eyes, the weak and small pulsation of the curotids, the effects of various kinds of treatment, and the absence of increased or even common vascularity of the brain upon examination after death, in some cases of this form of delirium. This opinion has been sup- ported by M. Glorget and several other pa- thologists, without having been imputed by them to its obvious source, viz. exhausted power of 39 the organic nerves supplying the vessels of the brain. 11. B. Delirium characterised by depressed or exhausted vital power, and morbidly excited vascular action, is by far the most common form; and is very frequently observed in the advanc- ed progress of continued, remittent, intermittent, malignant, and exanthematous fevers ; of acute inflammations ; and of several chronic diseases, particularly when they pass into the acute form. i It may also be occasioned by any of the nar- | cotic or acro-narcotic poisons, or from their ex- hibition in enemata ; and in some temperaments . and constitutions, by a small quantity of those in common use,— as by opium, stramonium, bella- donna, &c. I have more than once seen it pro- duced even by the preparations of hop and hyoscyamus taken in moderate doses. Its oc- currence from the medicinal exhibition of various narcotic and poisonous substances is noticed by various writers; — from cicuta, by We p fir and [Smetius (Miscell. p. 569); from belladonna, I by Pelargus and Valentini (De Maniacis | ab Usu Bellad. fyc.); and even by the superace- tate of lead, by Stoll (Rat. Med. par. vii. p. 317.) and Knight (Lond. Med. and Phys. Journ. vol. iv. p. 286.).—Dioscoridls (Mat. Med. 1. iv. cap. 63.), Westhhal (Pathol. j Damoniaca, p. 33— 36.), and Horn (Archiv. \ Nov. 1811, p. 510.), have noticed the occurrence of delirium from hyoscyamus exhibited in clys- ters* Poisoning by various substances, as the Lolium temulentum, and some of the narcotics just mentioned, generally occasions delirium. It may also arise from indigestible substances taken into the stomach. In all these cases, in addition to the states of the system connected with the appearance of this affection, there is generally increased excitement of the circulation in the brain, relatively to that in the rest of the body; and not infrequently an impure or altered state of the circulating fluid. The delirium occasioned by the protracted use, and the sudden disuse, of narcotics or spirituous liquors, by erysipelas, and retrocedent exanthemata, is of this kind, between which and delirium tremens there is often a close resemblance. 12. C. Delirium occasioned by inflammatory action of the brain or its membranes, when the inflammation takes place primarily, is seldom at- tended by very manifest exhaustion of vital pow- er, at least to the extent of the preceding forms. When, however, the inflammatory action is very general throughout the brain or its membranes, or when it supervenes on continued fevers or erysipelas, and is attended with serious effusion, vital depression is more apparent, and its termi- nation in, or alternation with, coma, more com- mon. This state of delirium, particularly when it proceeds from concussion or external injuries, is often phrenitic or maniacal — the Delirium ferox of authors — as respects the exaltation of muscular force. It is occasioned by all the caus- es stated to produce inflammation of the brain, particularly suppression of critical or accustomed evacuations, eruptions, or discharges; anger; the exciting passions ; metastasis of specific inflam- mations ; the ingestion of spirituous liquors, &c. Whilst the protracted use of intoxicating beve- rages, &.c. occasions delirium tremens, unaccus- tomed intoxication sometimes produces the dclir- 494 DELIRIUM —Prognosis—Treatment. ium now being noticed, by inflaming the brain. This form of the affection is often complicated with convulsions, contractions of the limbs, pa- ralysis, &c, particularly when the substance of the brain is organically changed; and is, when thus attended, verv much more dangerous. (See Brain—Inflammations of, § 164.) 13. iv. Lesions observed in fatal Ca- ses.— In the first form of this affection, scarcely any, or no evident change, is found in the brain or its membranes, beyond either a somewhat increased or diminished vascularity, occasionally with a slight increase of the consistence of the cerebral substance, or of the fluid in the ventri- cles. In many cases, all the parts within the cranium are apparently sound. In the second variety, and wherever delirium is unattended by marked disorder of the muscular actions — when it is without extreme prostration, or convulsions, or paralysis — the chief changes are, increase of the consistence of the brain, and of the fluid contained in the ventricles, injection of the pia mater, sometimes with infiltration of serosity, and occasionally a somewhat deeper shade of colour in parts or the whole of the cerebral substance. M. Georget remarks that pathological inves- tigations do not confirm the opinions of some authors, who impute the cause of delirium and convulsions to inflammation of the arachnoid ; and that even epileptics and the insane seldom present the appearances usually caused by arachnitis. They have probably confounded in- flammation of the membranes and periphery of the brain with the usual manifestations of de- lirium ; and thus imputed the changes observed in the former, to the latter. In the third form of this affection, or when it is attended by the lesions of muscular action noticed above, the ap- pearances observed are more completely those usually found after inflammation. Indeed, deliri- um frequently occurs, but not uniformly, or even generally, in nearly all the inflammatory diseases of the brain or of its membranes, and occasion- ally in the advanced stages of the organic changes limited to parts of this organ. (See art. Brain.) 14. v. Prognosis.—The great diversity of the results furnished by post mortem investigations will show the difficulty of appreciating aright the conditions of the brain in delirium, and of coming to a correct conclusion as to its issue. When it is sympathetic of disease of remote organs, the worst opinion should be formed of the result. Delirium occurring in the advanced stages of diseases of the lungs, stomach, or bowels, is a most dangerous symptom ; and when it super- venes in slow and consumptive maladies, it rarely remits, and death is not far distant. It se'dom appears as a sympathetic affection, until the pow- ers of life are greatly depressed, and the pulse is very much increased in frequency and dimin- ished in tone. Dr. Gilbert (Krankheiten der Franzos. Arm. p. 48.) observes, that delirium prevailed in the fevers which accompanied the French wars in Germany, in proportion to the frequency and weakness of the pulse, — a fact fully supporting the inference at which I had long ago arrived. On the other hand, when it appears in an intermittent or slight form, or from the operation of the less intense causes upon delicate and nervous constitutions, and without other grave symptoms, although evincing the se- verity of affection, it is not, in itself, a danger- ous occurrence. When it follows capital ope- rations, or severe injuries of any kind, it very often indicates the developement of inflammatory action of the brain of a most dangerous or rapidly fatal form. Delirium is most frequent in females, in the nervous temperament, and in young per- sons above the age of eight or ten years ; but it is, in such cases, a less unfavourable symptom. It is seldom observed previously to the fourth or fifth year,—convulsions usurping its place at an earlier age : but, when it occurs thus early in life, it is a sign of great febrile excitement, with either determination to, or acute inflammation of, the membranes or periphery of the brain. If it be continued, or alternate with coma ; or if it be complicated, with extreme prostration of muscular power, or with convulsions, spastic contractions, paralysis ; the existence of inflammation of the brain, to the extent of producing organic change and extreme danger, maybe inferred. Pere rius, Piso, and many other writers, have contended that furious and sad or fretful delirium is more un- favourable than that which is tranquil or lively; and the observation seems to be nearly correct The prognosis of sympathetic delirium should, however, not be founded so much upon its form, and the other symptoms referrible to the cerebro- spinal system, as upon the nature of the primary malady; for it is not the delirium which is in it- self dangerous, but the disease upon which it supervenes ; the circumstance of its occurrence evincing the very sinking condition of vital pow- er. M. Georget truly states, that the sudden cessation of delirium and agitation, attended by want of recollection of the previous state, by great debility, irregularity of the action of the heart, and loss of temperature in the extremities, nose, and ears, is a most unfavourable omen ; and often accompanies the termination, by gangrene, of inflammation of some important organ, always in- dicating approaching dissolution. When delirium accompanies fevers, particularly those with deter- mination of blood to the encephalon, or inflam- mations of the brain or of its membranes, it often yields favourably to epistaxis, copious alvine dis- charges, and other critical evacuations. (See art. Crises.) 15. vi. Treatment.—When the inexperi- enced practitioner, in his endeavours to obtain information as to the treatment of this affection, finds remedies of the most opposite kind very con- fidently recommended by writers, — venaesection by one, bark and stimulants by another, emetics or purgatives by a third, and digitalis, antimo- nials, &c. by a fourth, — he is at a loss how to act ; and arrives at the conclusion, that if one be right, the others must necessarily be wrong. The fact, however, is, that all of them are partly right, but ajso partly wrong. The circumstance of this affection having been hitherto viewed without reference to the very different states or grades of vital energy with which it is often asso- ciated, or to the condition of circulation in the brain, and its division into idiopathic and symp- tomatic,— either of these divisions presenting the different forms I have endeavoured to dis- tinguish,— has led to, and perpetuated, the empirical manner in which it has been treated. It is necessary to ascertain not only the origin and morbid relations of this affection, but the DELIRIUM — Treatment. 495 phenomena attendant upon it at the time of in- vestigation ; more especially the condition of the secretions and excretions, the temperature of the head, the state of the pulse in the carotids and temples, the appearance of the countenance, and the state of muscular power and motion. These will at once indicate to the observing practitioner the existing pathological condition causing the affection, — will enable him to assign it to one or other of the forms above distinguished, and there- by to prescribe for it appropriate remedies. 16. A. The first form of this affection (§ 10.) will be most benefited by quietude, gentle restor- atives, and nourishment; by a moderately cool, pure, and frequently renewed air ; by the tepid affusion on, or cooling applications to, the head, if their be any increase of its temperature ; by warm pediluvia ; by camphor conjoined with re- frigerants and cardiacs, or with sedatives; and, if the vital depression be very great, the head cool, and the carotids pulsating weakly, by the prepar- ations of quinine or bark, of assafcetida, valerian, musk, camphor in large doses, with those of am- monia, opium, &c, exhibited by the mouth, and in clysters : or by small quanities of mulled wine or negus. In the more purely nervous delirium, or when it occurs from operations, anxiety, fear, and injuries of parts at a distance from the head, I opium, given by the mouth, or in enemata, as re- commended by M. Dupuytren, will be most beneficial. If it be attended by much agitation, narcotics — as opium or hyoscyamus—in full doses, either alone, or with camphor, assafcetida, soda, or ammonia, &c; the acetate or muriate of morphine, with aromatics and cardiacs; quietude, in a cool, well-ventilated, and darkened apart- i ment; the tepid affusion on, or cold-sponging, the head, if its temperature be increased; and warmth to the lower extremities; are the chief remedies, i 17. B. In the second form of this affection (§ 11.), if there exist signs of determination of blood to, or of congestion in, the head, bleeding by cupping, or leeches applied behind the ears and below the occiput, the affusion of a stream of cold water on the vertex, and purging, are amongst the most efficient means that can be em- ployed. If the delirium be attended by stupor, I or tendency to coma, or by subsultus tendinum,, picking of the bed-cloths, &c, blisters to the nape of the neck, and the treatment advised in the article Coma, will be requisite. If the deli- j rious stupor be not removed by the more usual remedies, and if it have arisen from erysipelas of , the head, incisions of the scalp of the occiput, as | recommended by Copland Hutchison, may be practised. When there is no very considera- j ble heat of the head, or when the extremities are cool, and the morbid secretions have been purged off, full doses of camphor (F. 494. 496. 903.1 906.) may be exhibited. If the pulse be very \ weak, and the prostration of strength very great, the preparations of quinine or of bark, or of am- monia, camphor, assafcetida, valerian, musk, &c, with aromatics and cardiacs, or even wine in the form of negus, should be resorted to. When, with the vital depression and increased vascular action characterising this form of delirium, there are appearances of a morbid state of the circulat- ing fluid, we should endeavour to rouse the vital energies at the same time that we excite the secreting and depurating organs, by exhibiting camphor with the chlorates (the oxymuriates) of the alkalies (see F. 439. 845. 847. 928.), and the resinous purgatives with bitter tonics and stimulants (F. 492. 504. 572.). In such cases, the treat- ment recommended in the articles Blood (§ 156, et seq.), and Fever, will also be appropriate. As soon as stupor and a tendency to coma appear, in addition to the medicines now suggested, ca- thartic and stimulant enemata (F. 139. 149.), or an active purgative draught (F. 216.), should be exhibited, and repeated according to circum- stances ; and if these fail, blisters, sinapisms, rubefacient cataplasms or liniments, may be re- sorted to. The terebinthinates have been em- ployed by me since 1819, with great benefit, in this and some other forms of febrile delirium. The practice has lately been favourably noticed by Dr. Graves (Med. and Surg. Journ. vol. ii. p. 782.). If the head be cool, and the pulse, particularly in the carotids, be weak, small, and very frequent, either in this or the preceding form, all revulsants from the head, even the keep- ing it elevated, or warm pediluvia, will be inju- rious ; and may convert, as Dr. E. Gilchrist (Edin. Med. Essays and Observ. vol. iv. p. 358, et seq.) long ago remarked, a tranquil, into a most violent, delirium, which may soon terminate in fatal exhaustion. In both the first and second forms of this affection, the practitioner should not be induced to resort to lowering measures, merely because the muscular force is momentarily in- creased, and the patient is violent, restless, and agitated. If, with this state, the pulse is very fre- quent, small, weak, or irregular, and the head not very hot, a restorative and soothing treatment will be more beneficial. I have repeatedly ob- served, that this form of the affection, when su- pervening on protracted and exhausting disease, has been almost immediately subdued by small quantities of warm spiced negus ; by camphor, with capsicum and opium or hyoscyamus ; and by frequently sponging the head with cold or tepid water, when its temperature has been increased, or by the tepid affusion. 18. C. The third or inflammatory form of delirium should be treated in every respect as described when discussing inflammation of the brain or its membranes. (See art. Brain.) General and local bleedings, cold affusions and applications to the head, &c, are indispensable in it. If the delirium be complicated with stupor, or coma, convulsions, contractions or paralysis of muscles, &c, vascular depletions and active alvine evacuation should be followed by external derivatives of a permanent kind ; by incisions of the scalp ; by issues, open blisters, moxas, the use of the tartar emetic ointment, dry-cupping, &c.; whilst the secretions, &c. should be pro- moted by mercurial and other alteratives, and the bowels fully evacuated from time to time by a cathartic draught (F. 216.), and enema (F. 149). In every form of the affection, the patient should be irritated as little as possible by opposition, but indulged as much as is consistent with safety. 19. D. I shall conclude by noticing the treat- ment recommended by some authors. — (a) The topical application of cold has been advised by every writer on this affection, particularly since Bartholinus so strenuously recommended it (De Usu Nivis Medico, cap. 25.). It may be 496 DELIRIUM—Treat vk nt. prescribed in the form of cold affusion, pounded ice, cold epithems, evaporating lotions on the head, or simple sponging. If, however, it be con- tinued too long, or after the morbid heat has been subdued, and the features have shrunk, it will be injurious, by depressing the nervous energies too low, and favouring the supervention of coma, or violent agitations, terminating in fatal ex- haustion. It is required chiefly in the third form of the disease ; but in the first and second forms, when the temperature of the head is in- creased, it should be cautiously employed, or the tepid affusion substituted for it. In these, how- ever, I have preferred that the scalp should be sponged with a tepid and very weak solution of the nitro-muriatic acid. — (b) Camphor has been nearly as universally prescribed. Buchner (De Prcestantia Camphora in Deliriis. Hala;, 1763.), and Tode (in Soc. Med. Hann. Coll. ii. No. 34.) especially recommended it, — the latter with mineral acids. It is a most excellent remedy when judiciously exhibited. If given at all in the third form of the affection, it should be in small doses, with nitre and antimony, or with digitalis. In the first form, it may be prescribed in larger quantity; and in the second, especially 1f there be stupor or coma, or a morbid state of the blood, in still larger doses, with tonics, antiseptics, ar- omatics, and cordials. — (c) Opium or hyoscy- amus is noticed by Percival (Lond. Med. and Phys. Journ. vol. i. p. 443.), Goubier (Journ. de Med. t. lxxxv. p. 244.), Dupuytren, and Kortum (Beytrdge zur Pract. Arzneywiss. No. 9.). In some states of the first and second forms of the affection, when it is purely nervous, or is attended by much agitation, watchfulness, &c, either of these medicines may be employed. In the more doubtful cases, either of them may be safely exhibited with camphor and James's powder. In the third form, particularly when it assumes a maniacal or violent character, and after depletions have been carried as far as may be thought prudent, and the bowels have been freely evacuated, I have repeatedly seen a full dose of opium or hyoscyamus, given either alone, or with antimony, or James's powder, and camphor, pro- duce the happiest effect. Any unpleasant symp- tom that may result either from too large doses of these narcotics, or from their inappropriate use, will readily be removed by the cold or tepid af- fusion on the head. The acetate or muriate of morphine, taken in a full dose of the spirits of pimeuta, or in any other aromatic spirit, has proved equally beneficial with opium, ia my prac- tice. The external employment of opium has been found very successful in delirium, by V. Chi- arurgi (Sull' Uso Esterno dell' Opio, 8vo. Flor. 1797.), Ward (Lond. Med. and Phys. Journ. vol. i. p. 441.) and Percival (Ibid. p. 444.) who have used it in the form of liniment (3 j. triturated with 5j. of adip. praep.), either with or without camphor. — (d) Purgatives have been justly praised by all writers on this affection. The ancients prescribed them in very large doses, and preferred the hellebores, which, with calomel and those I have already particularised, should be ac- tively exhibited, according to the strength of the patient. When the debility is great, they must be associated with a tonic and stimulant treat- ment.— (e) Emetics have been mentioned by several writers; and when delirium proceeds from the ingestion of narcotic, indigestible, irritating, or poisonous substances, or is connected with the accumulation of saburrae in the upper portions of the digestive tube, they are then requisite.— (/) Antispasmodics and cordials, particularly valerian (Warburg, Med. Beobacht, No. 16.) assafcetida (Wantfrs, Journ. de Mid. t. Ivi. p. 115.), musk (Kortum, loc. cit.), warm negus, and similar medicines, have been recommended; and are often of service, when the powers of life are much depressed.— (g) Blisters have been ap- plied to the head much too indiscriminately: I have seen them prove most injurious in this situation. Dr. E. Gilchrist, one of the best writers of his time, directs them both to the head and to the insides of the legs. I believe that they will prove beneficial in the former situation, only when the powers of life are sinking fast, and the delirium is attended by stupor, a cool head, and suuk or collnpsed features, as in cases of low or adynamic fevers. When this affection is con- sequent upon febrile determination of blood to the head, blisters on the insides of the legs, &c. may be useful derivatives ; but they often occasion so much pain and irritation in this situation, as to thereby counteract, particularly in the turbulent state of delirium, any good they might otherwise produce.—(h) Of the sedatives or contra-stimu- lants prescribed by writers, the preparations of antimony, particularly James's powder—digitalis, and the nitrate of potash, are the most deserving of notice. Wherever the delirium is connected with increased vascular action in, or determination to, the head, these medicines are of more or less service when judiciously combined with other ap- propriate remedies.Withe ring (On Digitalis, p. 33.) and Patterson (Med. and Phys. Journ. vol. v. p. 442.) strenuously advise the preparations of digitalis ; but they, as well as those of antimony, require much caution, if ventured upon in the delirium attendant on low or malignant fevers. It is chiefly in the maniacal or third form of this affection that they are most beneficial, and in it they should be exhibited in a decided manner; but in the first and second, particularly in the de- lirium of typhus, they are generally injurious. — (i) The actual cautery on the nape of the neck, and moxas, have been advised by M. Valentin (Med. and Phys. Journ. vol. xix. p. 432.), and several other Continental writers. — (k) Dr. Grant (On Fevers, 8vo. 1771.) recommends the patient to be allowed to dress and sit up when he feels anxious to do so ; but this, and several ju- dicious observations of this writer, are more fully adverted to in the article on Fever. The ob- servations made on convalescence from Inflamma- tions of the Brai n , and from Fever, are perfect- ly applicable to the management of convalescence from delirium. (See these articles.) BlBLIOG. avd Refer. —P. M. De Heredia, De Nat. Deli;ii, ejusque Causis, Oper. t. iii. p. 278. — Vehr, De Deliriis ex Ventricolo. Fr. 1662. — Boerhaave, Institut. § 566, et cet. — Stubbs, in Philos Trans. No. 36. —Kan Swieten, Comment, vol. ii. § 70S___Pererii Quaest. Med. xii. — Teichmeyer, De Defiriantium Furore et Demen- tia, 4lo. Jena; 1733. — Quelmalz De Epidemica Mentis Alienatione. Lips. 1752.; et De Delirio ex Lactatu. Lips. 1754. — Buchner, De Deliriis, vitain served principally in the first species, or in such instances of the second as approach it the nearest, that Dr. Clutterbcck and Dr. Bright have viewed this latter as the consequence of inflam- matory action in the arachnoid and pia mater. DELIRIUM WITH TREMOR—Treatment. 501 I believe, however, that inflammatory irritation, although sometimes an attendant on this affection, is not necessarily connected with it, and certainly is not the pathological state which produces it; and that, when present, it is not the only con- dition which is requisite to the developement of its pathognomonic characters ; exhaustion or de- pression of both tho nervous and sensorial powers being equally necessary to its supervention. It is probable, also, that the vital and nervous de- pression is increased by the morbid impression produced by accumulated secretions of a vitiated kind in the biliary system, and on the digestive mucous surface. This conclusion is deduced from a careful comparison instituted between the symptoms, the agents controlling them, and the morbid appearances observed upon dissection. From this it may be inferred that the pathological states in true delirium tremens, and in the delirium of typhus, are not widely different. It is probable that the state of the blood, the presence of con- gestion, and the greater affection of the substance of the brain, and of the organic functions, in the latter than in the former, may occasion all the differences of symptoms which exist between them; the vital exhaustion being nearly the same in both, or perhaps greater in typhus, and the nervous disturbance being more prominent in delirium tremens. 20. vi. Treatment. — Very opposite means of cure have been resorted to in delirium with tremor, owing to the circumstances above stated (§ 2.), and to the evidences of general as well as of local vascular excitement in some cases, or of nervous and sensorial exhaustion in others, or even of their co-existence with more or less pre- dominance of either pathological condition. When it is considered that the inability to distinguish between such manifestations of the disease as de- pend in a great measure upon vascular excitement within the head, and those which result almost or altogether exclusively from exhausted nervous and sensorial power, must, in some cases, lead to an unsuccessful if not an injurious treatment, the necessity of investigating these points, of en- quiring into the history of each case, and of arriving thereby at a correct diagnosis — which can be reached only by a strict reference to the existing pathological condition causing the morbid phenomena— before entering upon the treatment, will be evident. Having pointed out the means most beneficial in each of the species of this de- lirium above distinguished, the practitioner may apply them accordingly, and adopt more or less of either method, in order to meet the predomi- nating characters which intermediate or more anomalous cases may present. 21. A. Of the first species, or that with increas- ed vascular excitement.—This form of the dis- ease requires moderate depletion, preferably by cupping, or leeches applied behind the ears, and below the occiput; cold washes or lotions, or the tepid or cold affusion, to the head, whenever its temperature rises above the natural standard; the tepid bath, or the surface of the body to be sponged with tepid water ; purgatives combined with cordials, &c.,if the nervous power be much depressed, or if the attack be occasioned by in- toxication, particularly calomel with camphor or ammonia, or with both ; aperient and antispas- modic enemata (F. 134. 149.); and the liquor 40 ammonias acetatis with excess of ammonia, and camphor julap. Purgatives are well borne: they may be given energetically, and be often re- peated, in this state of the disease ; but they should always be associated with stimulants and I restoratives, and their action promoted by ene- mata containing assafcetida, the terebinthinates, &c. When the affection is caused by spirituous ' liquors, we should be extremely cautious not to carry the depletion, although local, too far ; and I upon the first indication of the subsidence of vascular excitement about the head, we should endeavour to anticipate, and prevent the con- sequent depression which will otherwise ensue, by exhibiting, in addition to the ammonia-cam- phorated medicine now recommended, moderate ! doses of opium, or of laudanum, with the view of quieting the perturbation of the frame, and in- ducing sleep. 22. In the cases of this form of the disease, in which the vascular excitement either is not so great as to require bleeding, or has been some- l what reduced by this practice, emetics may be immediately exhibited. Dr. Klapp, and other American writers, prescribe tartar emetic in fre- quent doses, in those cases which are referrible to the present species of affection, until it either has an emetic action, or nauseates and purges the patient ; and Dr. Blake confirms the result of my experience, as now stated, in recommending emetics of sulphate of zinc, assisted by the ad- ministration of antispasmodics and stimulants, such as aether, camphor mixture, coffee, &c, with the application of cold to the head, while the surface of the body and extremities are sponged with tepid water ; and, in some cases, bleeding, without being pushed so far as to increase de- bility. This treatment is, however, most appro- priate when the affection is the direct result of intoxication; but when it arises from other causes (§ 5.), vascular depletions, purgatives, cold appli- cations to the head, and a more sparing use of stimulants, are most appropriate. 23. B. Treatment of the second species, or true delirium tremens. — a. During the first stage we should endeavour to cut short the disease, by exhibiting, every hour, very small doses of lauda- num in effervescing draughts, with the carbonate of ammonia, in camphor mixture ; or the opium with full doses of camphor and ammonia ; and by administering clysters, with assafcetida, cam- phor, and tinct. opii. Dr. Carter, of Philadel- phia, advises the mistura assafcetidae with tinc- tura opii to be taken every hour or two. Dr. Bi.akk recommends the accustomed stimulus in moderate quantity, and at short intervals; but it may occasion a too violent reaction, unless the head be guarded by having frequent recourse to the tepid or cold affusion on it. In some cases, however, warm spiced negus or punch may be allowed, especially in> exhausted and old drunk- ards. This is the only period in which blisters should be employed — if employed at all. The nape of the neck, or the epigastrium, is the pre- ferable place on which to apply them. Anodyne and stimulating liniments (F. 297. 308.) rubbed over the epigastrium are, however, more effica- cious. In some cases, a warm bath will precede the use of liniments with marked benefit. 24. Of all the cases of the disease I have seen, there has not been one that has not indicated the .502 DELIRIUM WITH TREMOR —Treatment. propriety of prescribing cathartics, in order to remove accumulated secretious. From the quan- tity of very dark, offensive, bilious evacuations which they have procured, — often not until after their repeated exhibition, and even iu cases where the bowels had been open or relaxed, — 1 have concluded that collections of vitiated bile in the gall-bladder and hepatic ducts have fa- voured the supervention of this peculiar affection. Under this conviction, I have always exhibited, as early as circumstances would permit, an ac- tive chologogue purgative, generally a bolus con- sisting of about ten grains of calomel, with as much camphor, and a grain of opium, in conserve of roses; and, in a few hours afterwards, a warm stomachic and aperient draught, followed in an hour or two by an enema (F. 135.). The advantages arising from conjoining camphor, or large doses of ammonia, or capsicum, or other stimulants, with purgatives iu this disease, are manifest; for, by these or similar means, we shall succeed either in arresting its progress, or in pre- venting the depression which might follow copious evacuations — fears of which have paralysed the treatment of it. In all cases, but especially in diseases accompanied by low or melancholic de- lirium, accumulations of vitiated bile or other secretions should be suspected, and be removed : nor should we infer, from having at first failed in procuring their discharge, that no such disorder exists; for the most active, and even the most judiciously selected, cathartics may long fail in evacuating the thickened and morbid contents of the gall-bladder and hepatic ducts, particularly when their excitability has become exhausted by spirituous potations. 25. b. In the second sta^e — if it supervene notwithstanding the above means, or if the pa- tient be not seen until it has appeared — the treatment should be commenced by the ex- hibition of the calomel, camphor, &c, as pre- scribed above (§ 24.), if they have not been already exhibited, or if they have not procured copious, dark, and offensive stools ; and evacu- ations ought to he promoted by warm and sti- mulating aperient draughts, and by purgative enemata containing assafcetida, camphor, &c, or consisting of F. 130. 149. The greater number of the cases I have seen had been treated by able practitioners, according to the plan advised by the best writers, but without success — although purgatives had been given where the bowels had not been sufficiently open. In all these, this treatment was immediately put in practice, and assisted by cordial draughts containing some one of the ammoniated spirits, and aethers, &c, and by the enemata already alluded to. As soon as alviue evacuations were procured by these means, opium, either alone, or with ammonia or camphor, or with both, was prescribed iu full doses, and repeated according to its effects ; and although they were all severe cases, one only terminated fatally. 26. At this period of the disease, the warm bath, at a temperature of about 90J, will assist materially in tranquillising the patient, and pro- moting the effects of opium. Dr. Wright, of Baltimore, strongly recommends it; but it is not a new practice in delirium tremens, as he sup- poses ; and he is favorable to the use of Dover's powder, which, however, is more suitable to the preceding species. Although opium should be given in full or decided doses, combined as stated above,—(in from one to three or four grains—the smaller quantity being repeated twice or thrice, the larger not oftener than once, and after a longer interval, it should not be persisted in, unless suflicient time be allowed to elapse after each dose; for, as Dr. Pearson has observed, if it. does not succeed after its exhibition at first in a decided manner, it increases the intellectual con- fusion and danger. Some of the American phy- sicians have recommended enormous doses of this medicine. Dr. S. Brown gives from 5j. to 3ss., or even more, of laudanum for a dose. Dr. S. Jackson prescribes from ten to fifteen or even twenty grains of solid opium every two hours; and states, that four ounces of good laudanum having been given in twelve hours, partly by mistake, a sound sleep of twenty-four hours' duration, and perfect recovery, were the result. I ouly am surprised that the sleep was not that of death. These are not solitary instances of the extravagance, if not rashness, of some American practitioners ; nor, indeed, has the practice of giving excessive doses of laudanum in this affec- tion been limited to them. When we find thirty or forty leeches ordered to be applied to the throat of a child five or six years old in croup, and repeated oftener even than once, and the bleed- ing promoted, should we wonder that death ensues ? Feats of hardihood in medicine are too often the consequence of clinical and practical ignorance ; and they may be allowed to meet their own reward, as long as they are not ob- truded into the annals of our science, and thereby set forth to the inexperienced as examples to be followed. But when this distinction is conferred on them, it becomes the duty of those who record the progress of medicine, to note also, and to oppose, its backslidiugs by the severest repre- hensions. 27. I believe that large and frequently re- peated doses of opium iu this disease, as Dr. Wright, of Baltimore, has remarked, favour the supervention of coma, convulsions, or paralysis; and that the effects of an excessive quantity of this drug very nearly resemble the phenomena of the last stage of the disease, particularly towards its fatil close. This fact should not be over- looked, and should lead us to distinguish between the consequences of an injudicious treatment, and the worst features of the malady. It is the abuse of opium that is here argued against; its truly medicinal exhibition that is contended for, — iu a quantity which sound sense will dictate, and after accumulated and morbid secretions and excretions have been removed, the discharge of which might be impeded or interfered with by the immediate employment of this valuable remedy. I consider opium as necessary to the cure of this disease, as bark and analogous medicines are to the cure of ague ; but, as in their case, the morbid colluvies, which has at least disposed the system to be affected, and aggravated the malady, should be removed, in order that recovery may be ensured and be permanent. 28. In this stage of the disease, particularly when the delirium is attended by much agitation or violence, it is necessary to obtain an influence over the patient's mind by moral means. All irritating contentions, however, should be avoided; DELIRIUM WITH TREMOR —Treatment. 503 and the patient's wishes, when not likely to prove injurious to him, be indulged. By thus granting what is less material, he will more readily submit to what is important ; but he ought not to be left a moment without an attendant. Coercive measures will generally be found unnecessary, one ; and prussic acid, which was tried in the other, was equally unsuccessful. 31. c. If the third stage appear notwithstanding the above treatment, little hope of recovery can be entertained, as most likely serous effusion has become superadded to exhausted vital and nerv- if soothing and indulgent but firm treatment be ous influence. Nevertheless, medical aid should adopted, and the warm bath be occasionally | not be withheld, especially if the patient have resorted to. In a majority of instances, the above j not received it in the earlier periods, or have means will be followed by a remission of the , been treated injudiciously. The hair should be symptoms, and a disposition to sleep will mani- I removed from the head, and either a blister ap- fest itself,—sometimes, however, accompanied by | plied, or one of the liniments (F. 299. 308.) rubbed nervous rigors. Opium should now be left off, i upon it. A blister, sinapism, or other rubefacient, or its dose much diminished ; and the patient ' should also be applied over the epigastrium ; and kept as quiet as possible. His first slumbers are j camphor, ammonia, musk, capsicum, &c. lib— often short, broken or interrupted by startings, ; erally administered ; restoratives and stimulants or terminated by fright. If he awaken alarmed, \ being also exhibited in clysters. Mercurial lini- his d stress should be soothed, and a moderate ments containing cur.,phor may likewise he rubbed dose of opium with warm spiced negus, or punch j upon the inside of the thighs, and the warm bath may be given him ; these will generally secure a I resorted to. sound sleep, from which he will awaken in a ra tional state of mind. Afterwards it will only be necessary to support the strength by light and nutritious diet, and gradually diminish the quanti- ties of the restoratives that have been prescribed. 29. In cases characterised by much vital de^ pression, very frequent pulse and cold surface occurring in old and broken constitutions, 32. d. Certain modes of practice have been em- ployed, to which a brief reference may be made. Dr. Klapp, and some other physicians of the United States, have recommended tartar emetic in frequent doses, until it nauseates and purges the patient ; but this treatment is more appro- priate in the first species, or in such cases of the habitual drunkards and ] second as approach it most nearly (§ 15.). Dr. liberal use of cordials, jSperanza, of Parma (Bullet, des Scien. Med. and even a moderate quantity of the accustomed I Sept. 1830.), directs leeches to the head and anus, stimulus, in addition to the opium, should be ad-1 applies ice to the scalp, and gives calomel and ministered from time to time ; particularly if the j jalap, and subsequently prussic acid. This me- head be cool, the face pale, and the action oflthod is obviously suited only to the first species, the carotids not strong. On the other hand, in I and would be injurious in most instances of the those cases which were described (§ 15.) as ap-1 second. From the preference he has given to proaching the first species of the disease, cup-; the appellation adopted by J. Frank, — Swee- ping, or the application of leeches on the occiput, \phalis tremefaciens, — I would infer that he has or nape of the neck, or behind the ears, will be i never prescribed it in the true delirium tremens. requisite early in this stage; and full doses of j Dr. A. L. Peirson (N. Ewg Journ of Med. calomel, and the rest of the purgative treatment, with cold applications, or tepid affusions on the head, should be more actively employed, and precede the exhibition of opium. In this state of the disease, opium often aggravates the symptoms, unless it follow a judicious use of these remedies ; and other excitants are equally injurious. In these cases, James's powder, or antimony, either pre and Surg. vol. ix. No. 2. Ap. 1820.) states, that he gave very large doses of digitalis (sixty drops every three hours) after bleeding, and the pa- tient recovered ; but this was evidently a case of this first form of the disease. Dr. Pauli in- forms us that he has prescribed from three to six drachms of fresh ox-gall, in aromatic water, half a glass of brandy each morning, and two grains of viously to, or conjoined with, camphor and opium, ' the watery extract of opium at night, in forty will also be productive of much benefit. 30. That state of the disease which conies on after external injuries or operations (§ 9.), I have imputed chiefly to the previously intem- perate habits of the patient. It requires the same treatment as the more nervous or vitally depressed cases now alluded to (§ 29.); and, as three cases, and has lost only one (Med. Gazette, vol. ix. p. 776.). The propriety of having re- course to moderate quantities of the stimulus to which the patient has habituated himself, in the depressed periods of the disease, and especially in those cases which present the more marked signs of exhausted nervous and vital power, has well as these, will be remarkably benefited by ' been insisted on by Dr. Blake, Dr. Ryan,&c, small clysters containing moderate doses of lau- | and admitted above, as well as by others ; and danum, administered after the bowels have been ! quinine, capsicum, the preparations of hop, and sufficiently evacuated, and repeated according to i various aromatics and cordials, may be also used circumstances. This treatment has been much re- ! as adjuvants of opium. lied upon by M. Dupuytuen ; but if it remove not J 33. e. During the treatment, little or no nour- the disorder, after sufficient time has been allowed ishment is desired, or even required : arrow-root for its operation, camphor may be added to it ; ■ and sago, with a little brandy or white wine, may and ammonia, musk, ether, &c. be given in suit- however, be given from time to time, particu- able vehicles ; or a moderate quantity of the pa- ' larly if* the patient wish it. When he becomes tient's favourite beverage allowed him, as su« gested by Dr. Colles. Of two cases recently- reported (Med. Gazette, vol. vii. p. 2*7.), which confirm the view 1 have taken of the origin of traumatic delirium in that state of constitution convalescent, the diet should be very light, but nutritious ; and a suitable beverage, iu moderate quantity, be allowed. During recovery, the state of the digestive functions ought to be attended to, and promoted by tonics, and by aperients which intemperance induces, opium failed in' whenever the bowels are torpid. I have never 504 DENTITION, DIFFICULT —Pathology ok. attended by signs of increased irritation as red- ness or tumefaction of the gums; by various cuta- neous eruptions ; by greater fretfulness, sometimes sickness and feverishness towards n.ght with restlessness, fits of crying, and sudden starlings from sleep. These may be the only ailments, which may subside either partially or altogether as soon as the tooth has passed the surface, and return shortly before others come in sight ; but not infrequently, particularly in this class of pa- tients, disorders of the prima via, particularly chronic diarrhoea, slight dysenteric affections, or slow remitting forms of fever, obstruction or enlargement of the mesenteric glands, obstinate and ^curring coughs, tubercula degeneration in the lungs or digestive tube, marasmus, &c, su- pervene more or less rapidly. 4. ii. In children who are of a plethoric rather than of a robust habit of body, and which Dr. J. Clarke has, with much justice, ascribed to over- feeding, the gums are often swollen and painful, the face flushed, the head hot and pained ; and all the symptoms of inflammation of the mem- branes of the brain, or of inflammatory fever with determination to the encephalon, frequently supervene. In them, the symptomatic fever \s generally high, and attended by great thirst, nausea, vomitings, constipation, and occasionally by drowsiness or stupor, or by great irritability and restlessness, or by both states of disorder al- ternately ; sometimes by short broken slumbers, from which the child awakens in a state of alarm, or in a fit of crying ; or by convulsions, di- minished secretion of urine, and other signs of cerebral affection. These are the usual con- comitants and symptoms, or consequences, of difficult dentition"; but they do not always stop here ; for they often run on into more serious disease, — such disease, however, occasionally appearing more abruptly and without these pre- cursory ailments, at least in such degree or dur- ation, as to become objects of attention to the attendants, or to lead them to resort to medical aid. These maladies, although often occasioned either partly or chiefly by dentition, when oc- curring in children at that epoch ; and whether affecting the cerebral, the thoracic, or the ab- dominal organs, or the skin ; are still more fre- quently independent of this process, and therefore cannot be further alluded to in connection with it, than they have already been in another place (see Age, § 10.);—and, indeed, in most instances in which a close connection between them and difficult or morbid dentition is observed, it is that of concurrent effects of constitutional predis- position and of anterior changes in the organic functions ; the local irritation and sympathetic febrile disturbance either exciting morbid action in such organs or tissues as, from hereditary con- through the surface. These signs of disturbance ] formation or vice, are disposed to it ; or aggra known or heard of an instance wherein the state from which the patient has escaped, or the re- presentations of the medical attendant or friends, has effected a reformation of the habits which pro- duced the disease. However, the physician should discharge his duty, by stating to him the conse- quences that will 'accrue from persisting in them. Bibmog. and Refer. — S. B. Pearson. Observ. on Brain Fev r. Newcastle, 1801. — M'Whirter, in Med. aud Phvs. Journ. vol. xviii. p. 153.— T. Sutton. Tracts on Delir. Tremens &c. kc. 8vo. Lond. 1C13 — Arm- strong. On Brain Fever from Intoxication, in Edin. Med. and Sure Journ vol. ix. p. 58. 146 —Nirol, in Ibid. June 1821. — A. L. Peirson. in S. Enz. Journ. of Med. and Sure;, vol. iv. 1820. - S. Brown, in Amer. Med. Re- corder. April 1822. — Klapp, in Ibid. vol. i.; and Eclect. Repert vol. vii. p. 252.—Snow-len. in Ibid. vol. v.—Plan fair, On Del. Trem. in Transar. of Med and Phys. Sor. of Calcutta vol. i. p. 124 — Coates in North Amer. Med. and Surg. Journ. vol. iv.; and in Johnsnn'i Med.-Chirurg. Rev. volTviii. \. S. p. 457.—Clutterbuck, Lectures in La cet, vol. xi. p. 376. — B rkhausen in N. A. Med. and Surg. Journ. vol. vti.—Liveilld, Mem. sur la Folie des Ivrognes, in Mem. de I'Acad. Roy. de M d. torn i. 4to. Paris, 1828. p. 181. — Ryan, in Lond. Med. and Surg. Journ. vol. iii. p. 227. — Helis, in Archives Gen. de M£d. t xv. p. 430, - A. Blake. Pract Treat, on Delirium Tremens, itc. Rvo. 1830.; and in Edin. Med. and Surg. Journ. Oct. 1823, p. 501.—T. H. Wright, in Amer. Journ. of Med. Sciences vol vi.p. 17.—S.Jackson, in Ibid. vol. vii. p.861. — J. Car- ter, On Mania a Polu, in Ibid vol. vi. p. 321.—Ware On the History and Treatment of Delir. Trem. 8vo. Bost. U. S. 1831 —Bright Medical Deports, vol. ii. part i. p. 15, et seq. - Hin^eston, in Lond. Med. Gaz. vol. xi. p. 7.— Ellintson, in Ibid. p. 466.—J Johnson, reported in Lancet for March 23, 1833. DENTITION, DIFFICULT. — S v v. Dentitio dijficilis, Odontio Dentitionis, Good. Dyso- dontiasis, Ploucquet. Difficult Teething. Classif.— I. Class. 1. Order (Good). II. Class, 1. Order (Author). 1. Defin. — Slow~ or delayed evolution of the teeth, with signs of local irritation, and con- stitutional disturbance, often ivith disorder man- ifested especially in the digestive organs and nervous systems, occurring chiefly in weak or over-fed children. 2. A general view of the pathological relations of dentition was exhibited in the article Age (§ 10.); and, therefore, only that morbid con- dition of the process which is unattended by disease of an important organ, and is referrible chiefly to this process itself, although often caus- ing disease, or being accidentally associated with it, will be here noticed. 3. i. Dentition, in the most favorable cases, is preceded by slight salivation, by heat and fulness of the gums, occasional flushings, increased thirst, restlessness or fretfulness, and frequent endeavours to thrust things into the mouth, evidently to allay irritation or itching. These symptoms generally appear about the third or fourth month, and pre- cede the appearance of the teeth sometimes by several weeks ; and occasionally subside, and re- appear shortly before the tooth makes its wav are merely the necessary attendants on the form. ative processes going on in the gum. But very commonly in children of deficient vital power, and occasionally in those which are apparently robust, or rather plethoric from overfeeding, den- tition is either delayed, or is attended by more serious disorder, particularly while the canine teeth are being protruded. In delicate children, particularly those living in crowded towns, and low and ill-ventilated localities, this process is both late and slow in taking place, and is often vating previously existing disorder, and rendering evident what was before latent, or unobserved. In these cases, therefore, dentition is to be looked upon either as a principal, or as a concurrent excit- ing cause of many of those diseases which occur at the period of dentition,—but a cause most frequent- ly concurrent with improper feeding and clothing. 5. iii. A natural or slightly difficult dentition may be converted into serious disease, by the not uncommon habit of giving the infant food when- ever it cries from the irritation attending upon the DENTITION, DIFFICULT — Treatment. 505 process, and thereby overloading and further dis- ordering the digestive processes, which are already disordered by the frebrile disturbance generally accompanying it; whilst determination of the cir- culation to the head is favored by the practice of covering the head in-doors or when asleep, and by wearing thick felt hats during mild or warm weather. Brandis believes that difficult den- tition is the consequence of obstruction of the salivation which accompanies, and is salutary in, this process: Hecker, that it results from a mor- bid state of this secretion: Mylius, that it is the effect of disorder sympathetically induced in the liver: Thom, that dentition often occasions an acrimony of the abdominal secretions, which react upon the original seat of disorder, and upon the system generally; thereby rendering it difficult or morbid: Wig and, that the affections attending, delaying, and otherwise disordering, this process, are accidental complications merely; and John Clarke, that all such disorders are commonly the consequences of plethora arising from over- feeding. Now, in all these opinions, there is much truth; and one or other, or several of them, obtain in many instances, more, however, as con- tingent and related effects of the local irritation, than as causes of the difficulty of the process,— which irritation is the chief or concurrent cause of febrile disturbance, of disordered function, and at last of more palpable disease, according to the condition of particular organs at the time, and constitutional or acquired predisposition. 6. iv. The irruption of the second or permanent teeth may also be delayed or attended by sym- pathetic disorders, particularly in persons whose maxilla are insufficiently developed, and when the dentes sapientes, and the canine teeth, are ap- pearing. In delicate, nervous, and irritable sub- jects, swelling of the parotid and sub-maxillary glands, painful and sometimes periodic affections of the ear or face, slight or recurring ophthalmia, irregular convulsions, or epilepsy, and chorea, have, in some instances, been excited by this cause; and have disappeared upon the eruption of the teeth, or the removal of the local irritation. 7. v. The Treatment of difficult dentition should be directed with the intention—1st, of re- moving the local irritation; and, 2d, of subduing the sympathetic disorders associated with it. — A. The local irritation requires scarification of the gums whenever they are at all swollen or red; and particularly in the second stage of the process, when the tooth has reached the surface, whether there be redness and swelling, or not. The pro- priety of this operation has been, however, cal- led in question, particularly by Sternberg, Storch, Thom, and Brandis, on the plea of its inutility, of it occasioning ulceration or disease of the capsules of the teeth, and of the cicatrix which is soon afterwards formed being absorbed with greater difficulty than the other parts. But these are by no means valid objections—for its utility has been proved by the experience of Harris, Cowper (Anat. of the Hum. Body, §-c.^,Bromfield(06- servations,8fC. v. ii. p. 17.), Berdmore(Treatise on the Teeth, fyc. 8vo. Lond. 1770.), Hurlock Riedlin, Wedekind, Kennedy, Marley, myself, and most modern writers of experience: and, as to the contingent ulceration of the gums, it seldom or never occurs when the operation is judiciously performed; when the lancet is clean, not carried too deep into the gum, if lancing be performed early in the process; and when its edge is directed rather outwards, as recommended by Mr. Marley. That the cicatrix may oppose the passage of the tooth is certainly not proved ; but this, if it did, is no objection, as a repetition of the operation, is often necessary, and generally beneficial. M. Brouzkt (Sur I'Educat. Medic. des Enfans, t. i. p. 234.) advises the surface of the gum to be divided, from time to time, by the point of the nail,—a practice which possesses the advan- tage of not alarming the child, of being easily and readily performed, andofdelayingtheclosingofthe divided part. But care should be taken not to perform it until the nails have been well cleaned. 8. The propriety of allowing the infant to rub the gums with hard substances has been ques- tioned by Auzebi,Marlf y, and others, from an. idea that they will hereby become more callous, and absorbed with greater difficulty. But the truth of this is questionable. I believe that sub- stances pressed frequently between the gums, materially lessen the irritation and distressing itching felt in them, and promote the flow of saliva,—results of no mean importance in pre- venting the supervention of sympathetic disturb- ance. These results will be ensured, in cases of existing irritation, by frequently moistening what- ever substance is thus employed with borax mixed in a little syrup of senna. 9. Besides the above, various other means have been recommended in order to subdue the local irritation: the chief of these are — a preservation of a lax state of the secretions and bowels; leeches, particularly behind the ears (Syden- ham, KoRTUM,SroLL,LEROY,/our7i. deParis, 1784,); internal emollients (Paulus ^Eginata, 1. i. cap. 9., and Bekker, Hermet. Rediviv. p. 705.) ; various derivatives (Hufeland) ; calomel (Mylius and others); the alkalies (Hecker); coldapplied to the face (Wiganu); opium (Wedekind); and active purging (Van- dermonde and Portal, Anat. Midicale, t. i. p. 211.). The best means of promoting the se- cretions and alvine evacuations are, small doses of hydrarg. cum creta, conjoined with the dried sub-carbonate of soda, and, if the state of the bowels requires it, with the pulv. jalapse, given every night. Leeches behind the ears, and cold applied to the head, should never be neglected whenever the temperature of this part is in- creased, and other signs of determination of the circulation to it are observed. In such cases, active cathartics, calomel with James's powder, and the rest of the treatment recommended for cerebral diseases, are necessary. Blisters applied also behind the ears are the best external de- rivatives; but they should be removed as soon as redness is produced. Opium is very seldom ad- missible; but, if much irritation exist, the tepid bath and syrup of poppies, with small doses of the sub-borate or the sub-carbonate of soda, may be prescribed. If the gums become ulcerated, borax, or sulphate of alumina, or the boracic acid, in honey or syrup of roses, should be employed. 10. 5. The sympathetic disorders should be sub- dued as soon as they appear.—(a) If the head indicate vascular excitement, the means already specified (§ 6. 8.) should be directed; and if the symptomatic fever, with or without deter- mination to this quarter, be considerable, cooling 506 DIABETES. aperients, and saline and antiphlogistic diapho- retics, are requisite, with the cold affusion on the head, the tepid bath. &c.—(b) Constipation, or colicky affections, which are not infrequent during this epoch, should receive immediate attention ; and aperients, emollient laxatives, — as castor oil with two or three drops of oleum anisi, hydrarg. cum creta with sub-carbonate of soda,— and, if requisite, purgative and anti- spasmodic enemata, ought to be prescribed.—-(c) Care ought to be taken not to check a slight diarrhoea; but if it passes beyond this, emollients, demulcents, refrigerants, diaphoretics, alteratives, tonics, absorbents, &c. should be prescribed, according to the circumstances of the case, and be assisted by the semicupium, warm clothing on the lower part of the body, and occasional doses of rhubarb with magnesia and hydrarg. cum creta.—(d) In some cases, both vomiting and purging, or a slight form of cholera, or of choleric fever, supervene ; the stools being greenish, spinach-like, and offensive, sometimes terminating in a gelatiniform softening of the mucous surface of the stomach and bowels, as described by M. Cruveilhikr ; but more fre- quently without such disorganization,as M.Guer- sent has remarked. The classes of remedies just now particularized are also admissible in this affection. (See Choleric Fever of Infants, and Diarrhoea.)—(e) Watchfulness, irritability, frequent startings from sleep, with crying, &c. should always be dreaded, especially when the canine or anterior molar teeth are about to appear, as not infrequently being the precursors of con- vulsions, and indicating much sympathetic irri- tation of the nervous system with disorder of the digestive organs, and excited circulation in the encephalon. On the other hand, somnolency, particularly in plethoric children, evinces con- gestion within the head, which may be readily- converted into inflammatory action ; or it may terminate in effusion of serum: and either con- dition may usher in convulsive spasm of the larynx, the nature and morbid relations of which have been so little understood. In all these varying states and relations of disease, leeches applied behind the ears, lancing the gums, purg- atives, emollients, refrigerants, a cautious ex- hibition of narcotics, laxative and antispasmodic enemata, the tepid bath, cold or tepid affusion on the head, rubefacient and anodyne liniments (F. 298 308. 311.) rubbed along the spine, and, in delicate children, gentle tonics, are requisite, and should be modified according to the habit of body, and the particular features of the case. (SeeConvulsions in children; and Larynx— Convulsive spasm of.)—(/) The occurrence of obstinate coughs at this period should suggest attention to the state of the gums, with the use of demulcents and emollients, conjoined with laxatives, external derivatives, and diaphoretics. Leeches, also, ought to be resorted to, if the cough be attended by heat of skin, quick pulse, accelerated respiration, or if the child be ple- thoric.—(g-) Eruptions, also, on the head, be- hind the ears, or on any part of the surface, ought not to be suppressed by external applications; but the functions of the abdominal and depu- ratory organs ought to be promoted by alteratives and gentle aperients, and the utmost cleanliness of the skin preserved. H. C.—(a) During dentition, the head should be washed with cold water night and morning; and no other covering than that with which nature has provided this part should be put upon it when withindoors or asleep; and on no occasion should warm felt hats be worn, thin straw or white hats being lighter and cooler.—(6) The diet should be carefully attended to, and that only allowed which is easily digested; and even it ought to be taken in moderate quantitv. The child ought also to be much in the open air ; and. if the process threaten much constitutional or local disease, an entire change of air will often be advantageous. BirtLIOG. vxn REFER.—Hippocrates, Tlenl otfoiTO- iii n :, Opera, cura Vander Linden, vol. i. p. 590.— A tii's, Tclrah. i. ser. iv. cap. 9. — Avinnr.a,Canon. 1. iii, fen. 7. tract, i cap 16.—De Castrillo, De Dentitione. Va- ladol. 1757.; in Halhr's Bilil. Med. Pract. vol. ii. p. 119.— Paraus, Opp Chirurg I. xxiii. cap. C~.—Riedlin, Lin. Med. :695, p. 406. — Ort/ob, D Dentilioue l'uer. Dillicili. Lip«. 1691. -Sydenham, Opp. p. 248. — Harris, De Morbis Acutis Infantum, p. 28. — Beurlin, De Dentitione Diffi- rili. Altd. 1720.—J. Hurlock, Practical Treatise upon Dentition. Lond. 1742, 8vo.—Juncker, De Dentitione Dillicili. Hal. 1745. — Vandermonde An Infant, a Den- lit. Convulsionihus vel Soporibus repetitus Catharticorum l:»us. Paris, 1757.—Stoll. Pr.elcct. i. p. 247. ii. p. 414.— Wigand, Beitrage, heft. ii. p. 141.—J. Hunter, The Nal. Hi>l. of fh Human Teclh, &c. pp. 132. 234. — R. Blake, On the Struct, and Form, of the Teeth. &c. Dub. 1801. —Wichmann, Ideen zur Diagnost k, b. ii. p. 3.—Wagner, De Dentitione Diff ftdubiisCI. Wichniaiini Vindicata. Jen. 1798.—Thom, Erfalirungen und Bemerk. p.'2l. — Starch, Kinderkrankheiten, t. ii -- Brandis, Versuch ueber die Melastasen, p. 210. — Lmhrij, De Dent. Diff. Lips. 1800. — Wedekind, in Hufeland's Journ. der Pract. Heilk. b. ix. st. 1. p. 34. — Mylius, i> Ibid. b. xxvi. st. 2, p. 188.—Hecker, in Magazin fur Fatliol. Anat. und Phys. b. i. — Hufeland. Bemerk. ueber. Slattern, he. p. 341. — For, On the Diseases which affect Children in the first Dentition, in Nat. History of the Teeth. Lond. 1E03. 8vo. — Bichat, Anal. Generate, t. iii. p. 88. — Beaumes, Traite de la Premiere Dentition, et de .\l*lad. qui en dependent. Paris. 1805, 8vo. — Gardien, Sur les Mai. des Enfans, &c. —M. Good, Study of Med. vol. i. p. 50.—J. Kennedy, On the Management of Children in Health and Disease, 8vo. Lond. 1825, p. 297. — S. Palmer's Popular Illustrations of Medicine, 8vo. Lond. 1829, p. 127. — T. C. Haden, Ob- serv. on the Management and Diseases of Children, 8vo. Lond. 1827, p. 132. — Darwall, On the Management and Disorders of Infants and Children, &c. 8vo. Lond. 1830, p. 79.—Marley, On the Nature and Treatment of the Diseases of Children, 8vo. Lond. 1830. p. 90. DIABETES. Excessive Secretion of Urine.— Svn. .4u:~i n'c (a siphon; or from Hatfulm, transeo). Lienteria Urinulis, Tabes Urinalis, Diurrhaa Urinosa, Hydrops adMatulam,Pro- fluvium vel Nimia Profusio Urina, Cito Emis- sio Rerum qua bibuntur, Auct. Vet. Polyuria, Seidel. Diabetes Anglicus, Mead and Sauvages. Phthisuria Sacchainna, Diabetes Saccharina, Nicolas, Gueudeville, Hufeland. Diabetes Mellitus, Cullen and Sagar. Dipsacus, Hecker. Phthysuria, Beil. Harnfluss, Honigartige Harnruhr, Germ. Urinflod, Dan. Diabete, Fr. Flosso d'Orina, Ital. Urine-Flux. Classif.—2. Class, Nervous Diseases ; 3. Order, Spasmodic Disorders (Cullen.) 6. Class, Disease of the Excreting Func- tion ; 2. Order, Affecting Internal Sur- faces (Good). I. Class, 11. Orlij-.r (Au- thor, in Preface). 1. Dei in.— Urine secreted of a sweet taste and violet smell, generally in large quantity, with great thirst, dryness of skin, debility, and emaciation. 2. This disease was but slightly alluded to by Celsus. Arkt^us gave a tolerably complete history of it, which the majority of his followers merely copied. Alexander ofTRALLEsadded DIABETES — Symptoms. 507 nothing to either its pathology or treatment, ex- cepting the drawing of a comparison between it and lieutery; and Aenus, taking up the same idea, states, that the one affection differs from the other in as far as that the undigested ailments pass off, in the former by the urine, in the latter by the stools; an opinion which was afterwards adopted by Fernel, DuRET,ZACUTus-LusiTANUs,and others. But Willis was the first who advanced a rational theory of the disease. Since his time, opinions as to its pathology have been various, and the remedies recommended still more diversified. 3. Even up to the present day, the term dia- betes has been applied to various states of dis- ease:—1st. To that consisting chiefly of diuresis, or morbidly increased flow of urine, without ref- erence to its quality ; 2d. To that in which the urine is voided not only more frequently, and in larger quantity than natural, but also of changed quality, as respects certain of its constituents, viz. albumen and urea, either of which may be in excess ; and, 3d, to that in which a saccharine matter is either superadded to the other ingre- dients contained in the urine, or in part replaces them. To the last of these morbid states I shall limit the term diabetes, conformably with the views of Dr. Prout and M. Renauldin. The other morbid conditions of the urine will be no- ticed when treating of the pathology of this se- cretion. (See Urine.) Restricting, therefore, the term diabetes to that state of the urine char- acterised by the presence of saccharine matter, I have defined it accordingly. In consequence of the very- vague ideas which have but too gen- erally been entertained both as to the phenomena requisite to constitute this malady j and as to its various morbid relations, diabetes has generally been considered with reference to the quantity of the fluid secreted, without regard to the cir- cumstance alluded to by Dr. Parr and others, and judiciously insisted on by Dr. Prout, that the disease may exist for a long time, and the urine be extremely saccharine, without much, or even any, increase of its quantity ; and, when the urinary discharge is augmented much beyond natural, that it is much easier to reduce it even to the usual quantity, than to restore it altogether to its natural quality. 4. Symptoms.—A. The urine of diabetic pa- tients is generally of a pale straw or greenish color; of a faint and peculiar odour, sometimes resembling that of sweet whey or milk, or of vio- lets. Its taste is always more or less saccharine; and its specific gravity usually varies from 1-02-5 to 1-052. The quantity of urea is generally much diminished in diabetic urine : Dr. Prout and Dr. Henry have never observed it altogether absent; and there is little or no lithic acid. The usual saline ingredients in healthy urine exist in the urine of diabetes, but in diminished quantity, whilst their relative proportions continue nearly the same. Dr. Watt has found a little blood in it; but this is a rare occurrence : it much more frequently contains albuminous matter analogous to that of chyle. Dr. Henry has given a use- ful table, showing the quantity of solid extract in a wine pint of urine of different specific grav- ities from 1-020 to 1-050. The following ab- stract of this table will enable the reader to ascertain the quantity of solid matter diabetic urine may contain :— Specific guvuy com-pared with 1001' Quantity of solid ex- Quantity of solid ex- purls of wuter ai tinct in a wine pint. tract in a wine pint, 60°. in grains. nt. dr. scr. prs. 1020 382-4 0 6 12 1021 401.6 0 6 2 1 1022 420-8 0 7 0 0 1023 440-0 0 7 10 1024 459-2 0 7 l 19 1025 478-4 0 7 2 18 1026 497-6 1 0 0 17 1027 516 8 1 0 1 16 1028 536-0 1 0 2 16 1029 555-2 1 1 0 15 1030 574-4 1 1 1 14 1031 593-6 1 1 2 13 1032 612 8 1 2 0 12 1033 632-0 1 2 l 12 1031 651-2 1 2 2 11 1 3,5 670-4 1 3 0 10 1036 6ts9-6 13 19 1 37 708-8 13 2 8 1033 728 0 14 0 8 1039 747-2 1 4 l 7 1040 766-4 14 2 6 1041 785-6 15 0 5 1042 804-8 1 5 1 4 1013 824-0 15 2 3 1"44 843-2 16 0 3 1045 862-4 16 12 1046 881 6 16 2 1 1047 900-8 17 0 0 1048 920-0 17 10 1049 939-2 1 7 1 19 1050 958-4 1 7 2 18 This table enables us to ascertain with considera- ble precision the quantity of solid matter voided by a diabetic patient in a given time. Thus, suppose 10 pints are passed in 24 hours, of the average specific gravity 1-040, it is evident that this will contain llfxTT-l.. 2.. 6 = 15 .. 7.. 2, or upwards of a pound and a quarter of solid extract. 5. Besides the saccharine condition of the urine, the next most striking and constant symptom is its increased quantity. Sometimes the quantity voided is enormous. J. P. Frank details a case in which 52 lbs. were passed in twenty-four hours; and instances are by no means uncommon of from twenty-five to thirty-five pints having been discharged in the same time for weeks, or even months together. In some cases the urine has been said to have been nearly double the quan- tity of the whole ingesta,—a circumstance which has puzzled physiologists to explain, and has in- j duced some to believe that, in addition to the | colliquation of the solids of the body, absorption of moisture from the air actually takes place I during the disease in some cases, either through the medium of the respiratory organs or cutane- I ous surface, or both. I believe, however, that so i great a difference between the quantity of the j ingesta and urine, as here stated, is extremely | rare; although a considerable excess has been proved by Dr. Bardsley; and the experiments of modern physiologists have shown that the lungs may absorb moisture from the atmosphere, although the skin may be incapable of doing so. I 6. B. The constitutional symptoms are often ushered in by weariness and aversion from any exertion; by dryness and disagreeable taste in the mouth,the saliva becoming white and frothy; and by a sense of weight, heat, or pain, in the epigastrium, accompanied with alternate chills and flushings, or burnings of the palms of the hands and soles of the feet. To these supervene I dryness of the skin, much thirst, costiveness; a I saccharine state of the urine, with, and sometimes 508 DIABETES —Complications—Terminations—Duration. without, an increased secretion of it; a craving appetite, and all the symptoms constituting the disease. In many cases, the urine has evidently been saccharine, without much increase in its quantity, long before the attention of either the patient or practitioner had been directed to this secretion. In other cases, the disease attacks more suddenly, generally with dryness of the mouth and throat; dry skin; a feeling of heat and pain in the epigastrium, occasionally with headach, commonly with aching of the back and loins, and pain in the course of the urinary pas- sages; sometimes, as mentioned by Ballomus, a sense of cold in the loins is complained of. The urine generally, now much increased in quantity, presents the appearances already described, and deposits no sediment. The breathing is short, sometimes difficult or oppressed, with a short tickling cough ; sometimes muco-puriform ex- pectoration, and flying pains through the chest. The desire for drink and food increases ; the skin becomes rough or scaly; the tongue either loaded with a dark-coloured fur, particularly at its base, or unnaturally clean, and of a dark red, or purplish red hue; the mouth foul, dry, and clammy; the bowels constipated, the evacuations being difficult, painful, dry, and often without their natural odour. A hay-scent sometimes issues from the body, as first noticed by Dr. La- tham, and a similar halitus occasionally from the lungs. As the secretion of urine increases, the thirst and hunger become intolerant, and, in some cases, the latter amounts to complete pica, as stated by Sprengel. The sense of heat and ! burning at the epigastrium is exasperated, and extends in the direction of the urinary passages, I frequently with phymosis, and some degree of uneasiness or inflammation about the external orifice of the urethra. The secretion of the prostate—but not the semen, as loosely stated by some writers—is sometimes voided after the dis- charge of urine; and the patient loses his sexual j propensities and powers. To these symptoms are generally, added chilliness, and great sensi- bility of cold; cold extremities, often alternating with burning of the soles of the feet, and slight oedema ; acid eructations, flatulence; painful ' muddy eyes; indistinct vision; headach or verti- go; dyspnoea or cough, and weariness on the least exertion; a sense of sinking at the epigas- trium; weight and tenderness about the pra- cordia; frequent sighing; listlessness; a weak, forgetful, distrusting, anxious, wavering, and peevish state of mind; and great depression of spirits. As the disease advances, the debility and emaciation increase. The skin becomes ru*ous and scaly, particularly over the abdomen; =and the veins large and distended. The fauces and tongue now assume a dark red tint, and are un- naturally clean; the gums spongy or partially absorbed; the teeth loose, and the breath foetid. In some cases, aphthnp appear in the mouth, and the gums ulcerate. The pulse is at first but little affected. Occasionally it is somewhat hard or frequent, particularly after a meal, or during the febrile exacerbations which usually occur in the advanced state of the malady. In the last stages, the pulse is often quick, sharp; or weak, small] and compressible. It is, however, very variable in different cases, or even in the same case. 7. C. The blood taken in the progress of the | disease generally separates into a loose, dark | crassamentum, containing a smaller proportion > of fibrine than the clot of healthy blood; and a whitish or light-coloured serum, resembling whey. Its analysis has been made by several eminent chemists, with the view of detecting saccharine matter in it. Nicolas and Gueudeville con- sidered it less animalised, and to contain a small- er quantity of fibrine, than healthy blood; but they found no saccharine matter. Wollaston, Marcet, Henry, and Prout, also failed in finding any of this matter in the serum; whilst Richter conceived that he could detect it by the taste, and, with many other pathologists, believes that it exists in small quantity in the blood, from , which it is so constantly eliminated by the action of the kidneys, as never to accumulate to the ex- tent of being detected by chemical agents; or that it is concealed by its combination or admixture with albumen. 8. ii. Complications.—I have scarcely met with a case of this disease which was entirely uncomplicated with pulmonic symptoms; and a similar remark has been made by Dr. Bardsley. i On this account I conceive that the appellation given to the disease by Nicolas and Gueude- ville, of Phthisurie Sucree to be extremely ap- propriate. It should, however, be conceded, that, in many cases, other organs participate in func- tional, and even in organic disease, particularly the digestive mucous surfaces, and the liver. In- deed, it may be often looked upon as a result of a breaking down of the system, often in conse- quence of intemperance and illicit indulgences, and exhaustion of the vital energies and assimila- tive functions, whereby several, or even all, of the organs concerned in the perpetuation of life suffer more or less. 9. iii. Terminations.—If unchecked by treat- ment, the debility increases, and pulmonic symp- toms, with hectic fever, if they have not already existed, seldom fail of appearing. Occasionally the disease passes into incurable dropsy. Not infrequently the discharge is much diminished, and more urinous, for a short time before death ; and, in some instances, the patient is suddenly cut off either by apoplexy, or, as observed by Dr. Prout, by a peculiar affection of the stom- ach occasioned by improper food, or by over- distension of this viscus from the excessive quan- tity of solid and fluid ingesta. 10. iv. Duration. — Diabetes generally con- tinues for an indefinite time, according to the suddenness or acuteness of the attack, the previous health of the patient, the nature of the exciting cause, the form of the complication, the diet and regimen prescribed, and the means of cure em- ployed. It is always exasperated during cold and moist weather. Frank states, that it is also worse in autumn. Hecker, Thenard, and Dupuytrfn, have known it to continue, with intervals of improvement, for many years ; and Oustkrdyck states that he treated a case that terminated unfavourably in a few days. When the issue is fatal, it commonly runs its course in a few months, aud is seldom of shorter duration than several weeks. I believe that the disease not in- frequently exists, for a considerable time at least, without any very sensible increase of the quantity of the urinary discharge, and that it is hence often far advanced before it comes before the DIABETES — Organic Changes — Prognosis, &c. 509 physician ; and that many cases which have been believed or stated to have been cured, have expe- rienced merely a temporary benefit, — the malady returning in all its severity from the slightest ex- posure to its more common exciting causes, or the least want of attention to the requisite diet and regimen. 11. v. Organic Changes are by no means constantly observed after diabetes, even in the urinary organs; and, when present in them, are not such as may account for the disease; but, as Hecker has justly contended, are rather its effects than its causes. Rutherford, Home,Dupuy- tren, SEGALAS,and Dezf.imeris, have found the kidneys somewhat enlarged and vascular. BoNET, M0RGAGN1,M0NR0, IIE RTZOO , Ca W- ley, Desault, and Hecker, have observed them only more flaccid than natural: and Cruick- shanks, Reil, Rutherford, Duncan, and Baillie, have remarked merely a more turgid state of their blood-vessels ; which Frank and Vetter have stated to have been more lacerable than in the healthy state. In rarer instances, one or even both kidneys have been observed much small- er than usual (P. Frank, Muller.) Hydatids have been found, by Beer, filling and distend- ing them enormously ; and calculi have been de- tected in their pelvis by Baillou. Ruysch and Hecker met with cartilaginous induration of their envelopes and cortical substance; and Brodie found their structure hard and gristly. Muller mentions enlargement of their nerves ; and Duncan states that the splanchnic nerves were all enlarged to three or four times their natural size, in a case he has recorded. Conradi observed the pelvis of the kidneys enlarged so as to contain a small orange ; and Ruysch, Ru- therford, Reil, Hecker, and Clarke, remarked considerable dilatation of the ureters. Increased size of either the pelvis of the kidneys, or of the ureters, or urinary bladder, or even of them all, is not infrequent. In some instances, the bladder is thickened, or contracted, and slight- ly inflamed, and the prostate enlarged. All the urinary organs, however, have been found as frequently natural, even by the authors now mentioned, as presenting the above changes. 12. Next in frequency to enlargement and flaccidity of the kidneys, the mesenteric glands have presented morbid appearances. Ma s c a g n i , JuNCKER,lllMLY,REIL,H0ME,CAWLEY,and Hecker, have found them enlarged, obstructed, and otherwise changed; but they also have been met with perfectly natural, by the same authors, as well as by others. Rutherford and Monro have observed enlargement, softening, and in- creased vascularity of the absorbent glands gene- rally. The thoracic duct has, in a few instances, been found greatly enlarged and dilated. The lungs are, perhaps, as frequently diseased as any other organ. I have never seen a case examined in which they were perfectly healthy. Luroth, Segalas, Dupuytren, and Horn, have sev- erally observed tubercles in every stage of their progress; ulcerations, tubercular excavations, hep- atisations, and purulent collections or disseminated vomica?, in the lungs, as well as inflammation of the pleura, and its consequences—adhesions of the pleura, &c. of the pericardium and pleura, serous effusion into the pleural cavity, &c. M. Luroth detected, in addition to hepatisation of, and ex- 41 cavations in, the lungs, aneurism of the pul- monary artery, the kidneys being sound. Similar states of the pulmonary artery, lungs, and kid- neys, were found in a case recorded by M. Lorstein; the lungs being extensively tuber- culated, hepatised, and adherent to the thorax, without any manifest thoracic symptoms during life. The digestive organs have been next most frequently diseased. Dupuytren and Segalas have observed a more vascular state than natural of the digestive mucous surface, but without any organic change of the stomach, or intestines, beyond dilatation of the former, and of the duodenum. Rutherford and Baillie always found the stomach healthy. The liver is more fre- quently diseased. Mead states that it was always altered in structure ; whilst Cullen, Franck, and Home, generally observed it natural. Caw- ley and Hecker have commonly detected organic change of this viscus. The spleen and pancreas have seldom presented any lesion. MicHAeLis, Conradi, and Hecker, detected chyle imperfectly mixed with the blood in the large vessels and cavities of the heart; and the same authors, and Marshall, remarked a cho- colate appearance of the blood in all the vessels. Dr. Rutherford states that the blood was black and fluid in all the cases he inspected. In the cases I have seen examined, the mucous surface of the stomach, and of the upper parts of the small intestines, was rugous and vascular. The lungs were congested or hepatised, or tuber- culated and excavated, or their pleurae adherent. The heart was flaccid, soft, and small; the blood dark and semi-fluid; the kidneys congested with dark blood, and somewhat large; the super-renal capsules somewhat indurated ; and the renal ganglia more than usually large. But these j changes were not uniformly observed; several of j them were wanting; and in one or two instances, no decidedly morbid change was delected. Upon j the whole, therefore, post mortem research has 1 thrown but little light on the nature of diabetes, further than showing that it is the result of a morbid condition of several, if not all, of the assimilating and excreting viscera, and not of any one of them. 13. II. Prognosis and Diagnosis. — A. Al- though patients whose constitutional powers are not greatly reduced, may sometimes live for many years, under judicious treatment, in this disease, yet should the prognosis be upon the whole very unfavorable : a cure may, however, be effected by appropriate means adopted early ; but this result is comparatively rare, and should never be considered as perfect, unless the healthy quality, as well as quantity, of the urine be altogether recovered, and the strength and bulk of the body be restored. Partial, or even very great, relief is often afforded; but the malady after a while re- turns, and may proceed without admitting of relief to a fatal issue, or be again and again checked by treatment. Much depends upon the patients themselves, and the strictness with which the prescribed regimen is followed; for, as the disease often originates in excesses, a return to them upon partial, or tolerable, recovery, will bring back the disease. When we find it complicated, as it most commonly is, with organic disease of the lungs, liver, or lymphatic system, a favorable issue cannot be expected. Out of from twelve 510 DIABETES — Causes and Nature of. to fifteen cases I have treated, I know of two only at the present time that have perfectly re- covered. One of these, a married woman, who had previously been attended by an eminent writer on the disease, has continued perfectly well for six or seven years ; but although not yet thirty-five, the catamenia, which had disappeared before the developement of diabetes, has not re- turned. The chances may, perhaps, be estimated at about five or six, or even higher, against the patient ; but much will depend upon the quan- tity and quality of the urine, the progress of the disease, the age, visceral complications, con- stitutional powers, the state and functions of the skin, the degree of emaciation, and circumstances and character of the patient. I believe that the prognosis should be much more unfavourable where the urine is mellitic, than when it is not so changed, however abundant it may be. 14. B. The Diagnosis of diabetes mellitus is very readily formed from the sensible properties of the urine. (See the Symptoms, § 4.; and art. Urine.) 15. III. Causes. — A. Predisposing. Here- ditary predisposition to this disease has been re- marked by several authors. Dr. Prout has observed it in four instances. Isenflamm states that he knew of seven of the descendants of a diabetic patient, who died of the malady. Morton, Brisbane, Rollo, Blumenbach, Frank,Storer,and Clarke,also furnish sim- ilar facts. Diabetes is more frequently met with in the male, than in the female sex; and in persons who either are past the period of puberty, or are advanced in years. The true diabetes mel- litus is rare in children, whilst albuminous urine and enuresis are frequent complaints iu them. It is much more common in cold and moist countries, particularly those in which the in- habitants live chiefly on rye, or any other vege- table food, or are imperfectly nourished, than in warm and dry climates ; and is hence oftener met with in Great Britain, Ireland, Holland, Denmark, and Sweden, than in France and Germany; and in the western, than in the eastern side of this island. J. Frank states that he saw a greater number of cases of it in Italy, than in any part of Germany. Dr. Christie observed it more frequently amongst the inha- bitants of Ceylon, than in any part of continental India ; and imputes it to the moist state of the atmosphere, and their poor vegetable diet. The scrofulous diathesis also predisposes to it. 16. B. The Exciting Causes are not so pre- cisely ascertained as the predisposing, and their connection with the origin of the disease not so obvious as could be desired ; but the following, acting either individually or in conjunction, par- ticularly in the latter mode, may be considered as most commonly productive of diabetes, where a predisposition to it exists, either hereditarily, or from visceral disease:—Continued or repeated ex- posure to cold and moisture ; drinking cold fluids when the body is over-heated; suppression of an habitual perspiration, by whatever means ; acid- ulous or fermented liquors, particularly in malt liquors, cyder, &c; the exhaustion arising from excessive evacuations and morbid discharges, or from undue sexual intercourse ; great bodily and mental exertions; the depressing passions, such as anxiety, disappointment, &c. : and whatever occasions great exhaustion of the powers of life, and of assimilation is sometimes productive of this malady. Besides these, au- thors have adduced others as its occasional causes. Autenreith mentions the use ot acids and acidulous fluids; Boerhaave, Lister, Stedman, and Frank, the abuse of diuretics and diluents; Sydenham and Sknac, exces- sive horse exercise; Ruysch, Cheselden, and Latham, the existence of chronic abscesses and carbuncles ; Frank, the carrying of heavy weights; Bennewitz (Ossan's Jahresbericht, fyc. July, 1828.) relates the case of a female who was affected by the disease during two suc- cessive pregnancies ; Plouco_uet and others, have observed it result from falls, and injuries on the back, loins, and hips ; and Baillod, Brendel, Weber, Lanzoni, and Frank, the drying up of chronic eruptions, exanthemes, fluor albus, &c, or the suppression of haemor- rhages. It may be suspected, however, of the last named phenomena, that, instead of being causes of the disease, they are actually the effects resulting from the internal changes constituting its early stages — diabetes, or the internal changes leading to it, having commenced previously to the disappearance of the external disorders — for it has been often remarked that sores heal rapidly during the disease. Diabetes may, indeed, be frequently considered a remote effect in the chain of morbid causation; functional or even structural change of the assimilating viscera, particularly the lungs and digestive organs, existing for many months, or even years, before the increase, or the saccharine state, of the urine has attracted attention. 17. C. The proximate cause of diabetes is still extremely obscure, although several authors of deserved reputation have endeavored to ex- plain it. — 1st. It has been ascribed to a morbid condition of the kidneys. This is the oldest opinion that has been entertained respecting its nature. The Greek writers considered diabetes to be owing to relaxation, debility, and increased irritability of these viscera ; the irritability being, as they supposed, the cause of their morbid activity; and the relaxation and debility allowing the more liquid parts of the blood to pass through the excretories without restraint or change, and, consequently, in a crude state, like the food in lientery. The supporters of this doctrine adduce, in proof of it, those morbid changes that have been observed in the kidneys, without agreeing amongst themselves as to the particular changes which really constitute the disease. Some con- sider that they are essentially inflammatory. But they overlook the facts, that decided and unequivocal marks of inflammation of the kid- neys are seldom found in diabetes; and that when these marks are observed in other diseases, they have uniformly been accompanied by a diminished, or an entirely suppressed, instead of a more profuse, secretion of urine. Others, who conceive that diabetes is a disease seated in the kidneys, ascribe it to spasm, without stating in what tissues, or vessels, this spasm exists; and even without mentioning precisely whether the ! spasm is in the vessels of the kidneys, or of other parts. Camerarius first proposed this doctrine, in which he was followed by Cull * n, who after- wards abandoned it, and ascribed it to "some DIABETES —Caus fault in the assimilatory powers." Gueude- ville, likewise, partiaUy adopted this opinion, but conjoined it with another which I shall have to examine in the sequel, and stated that this dis- ease " is a consumption arising from a continual spasmodic deviation of the unassimilated nutritive juices to the urinary organs." Here, however, the spasm is not ascribed to the tissues of the kidneys, and we are left quite in the dark as to the parts thus spasmodically affected. But amongst the various supporters of the doctrine that the kidneys are the seat of diabetes, there is not one who has attempted to name the specific affection or state of those organs which consti- tutes the disease. Ruysch, Ritter, Stoel- ler, Cruickshanks, Richter, and Good, have considered it as resulting from a morbid af- fection of the kidneys; and several of them, be- sides others whom it is unnecessary to adduce, have contented themselves merely with stating this very vague opinion. STOi.LLERand Richter, however, conjoin this undefined " morbid affec- tion" with depraved function of the skin ; and Good considers that the morbid state is one of ex- citement. He remarks that the whole of the phe- nomena, observed during the progress of diabetes, are consequent upon the renal mischief, and that it is a much less complicated disease than has hitherto been imagined. How far this is correct, the experienced practitioner may decide for himself; but it is certainly not in accordance with my observations, nor with the closest atten- tion I have been able to give the subject. It is certainly indisputed, and the observation of the most experienced physicians have placed the matter beyond a doubt, that other organs and parts manifest disease very early in diabetes, and that the assimilative viscera and circulating fluids are very evidently affected. Now, the kidneys, being strictly eliminating organs, or emunctories, removing matters which are hurtful to the system from the blood, how can we con- ceive that excitement of these organs, the proxi- mate cause of diabetes according to Dr. Good aud others, can occasion a diseased state of other organs, diminished assimilating function, and especially a morbid condition of the blood itself, the morbidity of which it is the chief office of these organs to prevent, or to remove if in any way produced ? Dr. Wollaston attributes diabetes to a change in the animal electricity of the kidneys ; and M. Dupuytren, to their perverted, equally with their increased action. But the remarks now offered are also applicable to these opinions ; for the cause of these morbid states must be sought after either in the kidneys themselves, or in some other quarter. If the kidneys be primarily affected, how can the early disorder of other viscera be explained ? IS. 2d. The disease has been imputed to a morbid action of the stomach, or some of the as- sistant chylopoietic viscera. This opinion has derived support from the feeling of heat, pain, and sinking, which is so generally and so early complained of in this disease; as well as from the morbidly increased action of these viscera, par- ticularly of the stomach. Dr. Mead ascribed it to the liver, from observing the disease most fre- quently in those who were addicted to the intem- perate use of spirituous and fermented liquors. Dr. Rollo confines it chiefly to the stomach; and f.s and Nature of. 511 | states that it proceeds from " an increased action and secretion, with a vitiation of the gastric juice, and probably too active a state of the lacteal ab- sorbents,—while the kidneys and other parts of the system are affected only secondarily." Ac- cording to this hypothesis, the chyle is imperfectly formed, and exists in the blood either in a sac- charine state, or in such a condition as to be readily converted into a saccharine fluid during its circulation, and its passage through the kid- neys. That it is not at once converted into a sweetish fluid, and therefore that the morbid se- cretion is not elaborated in the stomach and other digestive viscera, seem to be proved by the fact, that no saccharine matter has been satisfactorily | detected in the blood, although Wollaston, Marcet, Bostock, Dupuytren, and The- nard, and more recently MM. Henry, Sou- BEIRAN,VAUO.UELlN,SEGALAS,andMr.KANE j have endeavoured to ascertain its existence. It | may, however, be admitted, that the saccharine matter may exist already formed in the blood, as is sometimes evidently the case in respect of urea, as has been demonstrated by MM. Prevost and Dumas, and be so rapidly eliminated by the action | of the kidneys, as never to accumulate it so as | to admit of detection by analysis ; or it may be granted, that the first part of the morbid process commences in the digestive viscera, and that it is afterwards fully perfected in the kidneys. But these are merely probable suppositions, which scarcely admit of proof. 19. 3d. It has been supposed that a saccharine and imperfectly elaborated chyle, instead of being | conveyed into the blood, is carried to the kidneys | and urinary bladder, by a retrograde action of the I absorbents. This hypothesis was first proposed I by Dr. C. Darwin, who conceived, that when a greater quantity of inebriating fluid than usual is drunk, at the same time that the lacteals are quickened in their power of absorbing it, the urinary branches of the absorbents, which are t connected with the lacteals by many anastomoses, | have their action inverted, and a large quantity I of pale, unanimalised urine is hereby discharged. Where the ingurgitation of fermented or other j exciting liquors is continued, or occurs often, the urinary absorbents at length gain a habit of inverted action whenever the lacteals are stimu- lated ; and a whole or great part of the chyle is then carried to the bladder without entering the circulation, and the body becomes emaciated ; and the urine is necessarily sweet, and the colour of whey. Numerous objections may be offered to this hypothesis. It is altogether founded on postulata ; and, moreover, it proceeds on the gratuitous idea, that the chyle is generally a saccharine fluid, nearly, if not altogether, resem- bling the diabetic discharge. Now, such is not the case ; for chyle contains but little saccharine matter. Besides, the structure of the lymphatics, and their connection with the vascular system, is completely opposed to their retrograde action. P. Frank has very materially moulded this hypothesis, and into a more plausible form, by relinquishing the untenable idea of a retrograde action of the absorbents. He conceives that diabetes is a disease of the lymphatic system, conjoined with excitement of the urinary organs ; that it proceeds from stimulation of both these by some virus formed within, or introduced from 512 DIABETES — Causes andNature of. without, and producing'a reverse effect to that oc- casioned by the virus of the rabies canina; so that, while the latter produces a dread of liquids, the former excites a constant desire for them. In support of this doctrine, he adduces the opinion of the ancients, that diabetes is occasioned by the virus of a serpent called dipsas, and hence the common name generally given by them to this malady. That it may be excited by the bite of reptiles, or even higher animals, is not impossible. Dr. Latham mentions a case pro- duced by the bite of a rat; and it not infre- quently arises, as remarked by Cheselden and Latham, from carbuncles, or chronic abscesses, where it may be presumed that a partial absorp- tion of morbid matter takes place. Frank sup- poses that the morbid matter occasioning the disease acts by inducing a morbid irritability of the lymphatic system, owing to which every other part of the frame is exhausted of its nutrition ; that the fluids, thus morbidly absorbed, are rapid- ly conveyed into the circulation, particularly the chyle to the kidneys, which concur in the morbid action; that the cuntaneous and other exhalations are hence completely arrested; and that the flux of saccharine urine is thus produced. This is certainly a more plausible doctrine than that on which it is evidently founded ; but, even conced- ing the morbid excitement of the lymphatic sys- tem and of the kidneys, the origin of this excite- ment in a morbid virus or matter is much more gratuitous, and the cause of the saccharine pro- perties of the urine is wholly unexplained. 20. 4th. Dr. Clarke, and more recently Dr. Marsh, impute the disease, iu a more espe- cial manner than has been done by other pathol- ogists, to the cutaneous surface, which, indeed, may be viewed as an important organ of the an- imal economy ; and they consider it " as a sweat driven in upon the kidneys, where this morbid determination keeps up a profuse discharge." This opinion seems to have been partially entertained by Ritter, Stof.llf.r, and Richter, who, whilst they ascribed diabetes, as we have seen, in part to a morbid state of the kidneys, conceived that a depraved function of the skin was also con- cerned in its production. There can be no doubt that suppression of the cutaneous functions is an early change, and that it contributes to the per- petuation and aggravation of the malady. 21. 5th. One of the most plausible theories which have been advanced, is that which refers diabetes to a dyscrasy or morbid condition of the blood, arising .from a diseased state of the as- similating powers of the frame. This doctrine is not materially different from that which was proposed by Willis and Sydenham, and more recently by Place, Desault, and Latham ; and, as well as being more accordant with the procession of morbid phenomena, has a more obvious relation to the exciting causes, ter- minations, and morbid appearances in fatal cases, than any of the theories now reviewed. Accord- ing to this doctrine, diabetes is not to be imputed to the derangement of a single organ or system of vessels merely, but rather to defective energy of the whole frame, particularly impeding the ad- vanced stages of the processes of digestion and assimilation. That the blood is not in a healthy state, and the chyle imperfectly assimilated to it, as well as the crasis of the whole circulating mass deficient, is sufficiently manifested in the appear- ances which the blood presents when taken irom the patient during life, and when observed in the vessels after death. Upon examining speci- mens of the blood taken from diabetic patients, MM. Henry and Soubeiran found the quan- tity of its fibrine and albumen one fourth less than is assigned to healthy blood by Berzelics andDARCET; and Bach e ton i remarked that oil of almonds passed offwith the urine, unchanged in its passage through the digestive and assimilating organs. The state of the blood, also, in the veins and cavities of the heart, is somewhat peculiar— generally being semi-fluid, sometimes resembling treacle, and very dark-coloured. That this state is not primary, but is a consequence of deficient vital energy of the organic nerves, and of the assimilating organs, in connection with impeded exhalation and secretion from all surfaces and organs excepting the kidneys, seems most pro- bable. Hufeland supposes, that, owing to the changed action of the kidneys, and the unassimi- lated state of the chyle with the blood, the former of these fluids, with the nutritous parts of the latter, containing the saccharine principles, are excreted with the urine, and occasion the phe- nomena of the disease. This opinion, in its ge- neral bearing, comes as near the truth, perhaps, as any that has been offered; but still it admits of reference to antecedent disorder. 22. 6th. I should, therefore, conclude, from what I have seen of, and thought respecting, this malady, that, owing to deficient or exhausted influence of the nerves supplying the assimilating viscera and vascular system, the chyle is not readily or perfectly changed into blood, nor are the nutritious parts of the blood attracted by, and identified with, the various structures : that this imperfect performance of the assimilating func- tions must necessarily be attended by deficiency of all the secretions and excretions excepting the urinary, particularly the cutaneous, the pul- monary, the intestinal, and the hepatic, as both classes of functions are under the influence of the organic system of nerves. Thus a redundancy of imperfectly elaborated blood must be the re- sult, a portion of which will be carried off by the kidneys, as in ordinary circumstances; for as long as these emunctories retain their powers, they are the appropriated safety-valves of the vascular system, by eliminating both the watery, the saline, and other elements of the blood, when they become excessive. These states and changes account for the simple excess of urine; the more watery parts of the blood being carried off by the kidneys, instead of being secreted from the cutaneous, the respiratory, and intestinal surfaces; and the action of the kidneys, being once excited in the manner now stated, becomes excessive, from the superabundance of the imperfectly ela- borated and stimulating matters contained in the blood circulating through them. The saccharine matter in the urine evidently arises from the mor- bid condition of the blood originating in the man- ner now explained ; the unassimilated elements readily assuming the mellitic combination, pro- bably in consequence of the state of vital action exerted by ^the kidneys during their excretion. What the precise nature of this action may be, cannot be easily ascertained ; but it probably is, as Dupuytren and others have supposed, a per- DIABETES —Treatment. 513 verted as well as an excited action : the morbid condition of the organic nervous influence, and of the blood, changing the vital functions of the kidneys, in addition to simply exciting them. That a morbid state of organic nervous influence throughout the tissues, and of the blood, exists in this disease, is shown by its principal phenomena, and by the fact that diffusive inflammation fol- lowed bleeding in two instances recorded by Dr. Duncan. 23. IV. Treatment.—The means of cure employed in this disease have been varied ex- ceedingly, according to the opinions entertained respecting its nature. Many remedies have also ' been resorted to empirically, without reference either to their mode of operation, or to the pre- sumed pathology of the malady. As it will be , useful to the practitioner, I will first exhibit a succinct view of the different modes of treatment! which have been recommended, venturing such remarks as my experience enables me to suggest; and afterwards I shall proceed to state the plan which has seemed most successful in my practice. 24. i. View of the Treatment proposed by Au- thors.—In estimating the degree of success which writers state they have derived from various re- medies, it should be kept in recollection that other morbid states of the urine, besides that which is characterised by the presence of sac- charine matter, particularly those consisting of excess of albumen and urea in, conjoined with augmented discharge of, the urine, have been con- sidered as constituting a variety of diabetes, — the diabetes insipidus; and that, owing to this circumstance, many of the methods of treatment which have been stated to have cured diabetes, have been successful only so far as respects a less difficult and dangerous form of disease, and one which is frequently no closer related to true diabetes than as respects the increased quantity of the urinary secretion. 25. A. Astringents have been recommended by many writers, and various remedies belonging to this class have received approbation. The greater number of the mineral, and some of the vegetable acids have been used, either alone or in combin- ation with other medicines. — a. Gilby, Ear- nest, Scott, and Brera have employed ni- tric acid, sometimes with much benefit. Brera recommends the internal use of this acid to be con- joined with mercurial inunction. I have given it combined with opium, the patient at the same time using the warm bath and animal diet. Some advantage was derived from this treatment for a considerable time ; but the disease returned. I have likewise conjoined the nitric with the mu- riatic acid, in equal quantities, and employed it internally combined with opium, and externally in the form of the nitro-muriatic lotion applied warm over the epigastrium and loins. This has certainly appeared a very beneficial treatment; but as it was not confided to alone, but conjoined with other means which I shall adduce in the sequel, it is difficult to determine the degree of benefit derived from it. 26. /* The phosphoric acid, both alone, and in combination with, or neutralised by, other sub- stances, has been recommended by Nicolas, Gueudeville, Latham, Sharkey, and Ve- nables. Dr. Sharkey speaks favorably of the phosphate of soda. It has the advantage of preserving a free state of the bowels, whilst it tends, in a very marked manner, to diminish the flow of urine: but I believe that more ad- vantage will be derived from it, as well as from the phosphate of iron, which has been strenu- ously recommended by Dr. Venables, in the excessive discharge of albuminous urine,—an affection frequently observed in young subjects,— than in the disease under consideration. 27. y. The sulphuric acid and its salts have received the sanction of numerous writers, who have generally prescribed them in combina- tion with preparations of cinchona, aromatics, opium, &c. I have exhibited the acid with the sulphate of zinc, and with the sulphate of quinine, as one part of the treatment adopted in the cases which have occurred to me; and, as from a large proportion of the means employed, benefit was derived from it for some time. The sulphate of alumina has been prescribed in a variety of forms, but most frequently dissolved in whey, by Do- ver, Brocklksby, Herz, Lindt, and many others. But its want of efficacy has been satis- factorily shown by Brisbane,Oosterdyk, and Frank ; the last of whom carried the use of it to a large extent, in order to test its effects. Dr. Wintringham applied the sulphate of alumina, dissolved in vinegar, as an epithem on the loins. The sulphate of iron and the super-sulphate of potash have likewise been employed in this dis- ease. The latter of these possesses the advan- tage of acting as a deobstruent aperient, and is hence often of much service. Dr. Eraser en- tertains a favourable opinion of the former. 28. <$. Several other astringents, as sumach, kino, catechu, in the form both of tincture and decoction, lime-water, &c, have beeu recom- mended ; but they seem to have been of no fur- ther service than auxiliaries to other means. The aqua calcis, used as common drink, either alone or with milk, has been praised by Willis, Schutz, Jarrold, Foth ergill, Watt, and Frank. Although astringents have been very generally employed, some doubts have been thrown upon their utility by Amatus Lusitanus, and others. Sydenham, however, expresses himself favourably respecting them when conjoin- ed with aromatics and opiates,—a mode of exhib- iting them which is certainly the most preferable, and the only way in which I have employed those now enumerated (§ 42.) in this disease. 29. B. Tonic astringents have received much attention, particularly from Stoeller, Fer- riar, Morton, Fahner, Frank, and others. Amongst those, cinchona, in decoction with the elixir of vitriol or with simarouba, or in powder with the uva ursi, in doses of a scruple or half a drachm of each, with half a grain or a grain of opium, and repeated every four or five hours; and the preparations of iron, either alone or with cinchona or cascarilla, deserve a particular notice. Tonics with catechu, kino, &c, and the vegetable bitters, as well as the mineral tonics, in conjunc- tion with opium, have severally been employed, particularly by Shee, Abrahamson, Roeber, &c. Under this head, I may notice the use of astringent wine, as having been recommended by Celsus, and, in modern times, by Willis and Morton. 30. C. Diaphoretics have been very general- ly recommended, and particularly by Roeber, 514 DIABETES — Treatment. Stoeller, Werner, M'Cormick, and Marsh, with the view of restoring the suppress- ed functions of the skin, and diminishing the de- termination towards the kidneys. Amongst the various medicines which have been exhibited with this intention, the putvis ipecacuanha comp. and opium with antimonials deserve a particular no- tice. I have prescribed these with full doses of camphor on several occasions with much benefit. This last named substance has been much praised bySHEE and Richter, who recommended it to be exhibited in large doses in mucilaginous emul- sions. Of this class of remedies, there is cer- tainly none more decidedly useful than the warm and vapor baths. Salzburger, Ritter,Wer- ner, Richter, HnNEKEN,and Marsh justly place much reliance on them. To these may, perhaps, be added the sulphur baths ; but I have had no experience of them. The promotion of a free and even copious perspiration by the constant use of woollen clothing next the skin, and active exercise, has been noticed by several writers; and, I am enabled to add, forms a most important part of the regimen to which diabetic patients should be subjected. 31. D. Alvine evacuations.—a. Emetics have been employed with advantage in some cases by Ettmuller, Riverius, Brendel, Mich- AeLIS, Rollo, Wintringham, Watt, and Richter, particularly early in the disease. It is chiefly at this period, or in subjects whose constitutions still retain some degree of vigour, that they are admissible, b. Purgatives have re- ceived less attention from writers on diabetes than they deserve. Trnka, however, has passed very just encomiums on them ; and they have likewise received some notice from Dr. Marsh and a few other recent authors. I believe them to be very generally beneficial, not only in as far as their occasional exhibition may remove morbid accumulations, and obviate constipation, which is so frequently an attendant on the disease, but also as regards a continued and decided use of them, so as daily to procure two or three copious evac- uations. With this view, full doses of rhubarb, or of the infusion of senna, with compound infusion of gentian, or of the phosphas soda, should be exhibited daily. There are few remedies that deserve a more favourable notice in diabetes than rhubarb. It received the warm approbation of Baglivi and Lister, who recommended it in conjunction with aromatics, and of Brockles- by, Morton, Buchwald, and Harris. Dr. Baillie prescribed it with laudanum. I have employed it frequently as an aperient, both in powder and infusion ; and combined it with veg- etable tonics, aromatics, and opium, with the intention of promoting the digestive and assimila- ting powers. It is one of the best medicines that can be used in this disease. 23. E. — a. Sulphur and the alkaline sulphu- rets have received a deservedly favourable notice from Autenreith, Redfearn, Bang, Rol- lo, and MiCHAens. The hepatised ammonia was particularly noticed by Dr. Rollo, with the view of furnishing to the system, along with a liberal animal diet, the elements which seemed to be wanting to the chyle and to the urinary secretion. The free use of sulphur, so as to pro- duce an aperient effect, is often beneficial. I have seen much advantage derived from it ; and I conceive that the sulphurets are often service- able as adjuvants to the general plan of treatment. Dr. Christie mentions them with approbation in his interesting details of cases treated by him in Cevlon. 6. Cantharides, either in the form of powder or tincture, exhibited alone or combined with camphor, have received a favourable notice from Morgan, Werner, Herz, Stoeller, &c. Wolff combined them with cinchona: but Brisbane, Busch, and Frank derived no advantage from them. 33. F. Opium, either in substance or tincture, alone, or combined with tonics and aromatics, or with astringents or with diaphoretics, with cam- phor, valerian, or with assafcetida, or even with the sulphurets, according to the varying features of particular cases, is, perhaps, the most general- ly applicable and beneficial remedy that has been employed. But it should be given in large doses, and its use persisted in, and so managed as not to prevent a free and continued action on the bowek If the dose be.sufficiently large, it will seldom con- stipate the bowels in this disease, or impede the action of purgatives and aperients ; and it will determine more sensibly to the skin, while it will more decidedly diminish the urinary flux than when prescribed in small doses. It is chiefly to Archigenes, Sydenham, Buckwald, and Warren, and afterwards to Gueudeville, Heineken, Money, Marsh, Carter, and others, that we are indebted for proofs of the great advantage to be derived from this medicine in diabetes. 34. G. a. Mercurial inunction has been re- commended by Scott, Lubbock, and others. Brera prescribed it at the same time with the internal use of nitric acid ; and Frank, with tonics ; he even advised it to be carried so far as to produce salivation. When diabetes is compli- cated with hepatic disease, this treatment will be requisite. I have seen it employed with some ad- vantage, alternated with the nitro^muriatic lotion applied on the hypochondria and loins, in a case of this description. When biliary derangement exists, the occasional exhibition of a full dose of calomel with rhubarb, or the compound extract of colo- cynth at bed-time, and followed, in the morning, by an active purgative medicine, will be found of service. — b. Medicines that act as diuretics may be supposed to be contra-indicated in diabetes. But they are not necessarily injurious ; for, if they have a beneficial effect on the body generally, or on the visceral disorders with which diabetes is associated, they may even be of benefit; and if the action of such medicines on the kidneys be energetic, they may change the morbid action in- duced in these organs by the disordered state of organic nervous influence and of the circulating fluid, and in this way prove beneficial. Among the different substances that have a diuretic effect, colchicum may be mentioned as having lately been sometimes prescribed in this disease, but chiefly on account of its sedative operation. It may be of some service in promoting the biliary secretion, in increasing the quantity of urea and uric acid in the urine, and in diminish- ing the irritability of the frame. Its good effects, however, require confirmation, and may proba- bly be ensured by combining it with ammonia or its preparations, or with camphor. 35. H. Nutrients in various forms have been DIABETES —Treatment. 515 strenuously recommended by Home, Rollo, Dupuytren, Nicolas, Oswald, Frank, Christie, and many others. Dr. Rollo par- ticularly insisted upon the nearly exclusive use of animal food, with the view of resisting the se- cretion of saccharine matter, and furnishing the elements of urea and the animal salts to the blood. There can be no doubt that the greatest benefit has been derived from this treatment. It should, however, be admitted, that it often fails ; and that, when it is too freely indulged in, it sometimes occasions a diarrhoea, which exhausts or even carries off the patient. With a knowledge of these occasional effects, Dr. Prout recommends it with very judicious restrictions, and to be taken with a moderate proportion of farinaceous food ; and Frank advises, in addition to it, the decoc- tion of Iceland moss, or of the althaea officinalis with milk. 36. /. Besides the foregoing, various other remedies have been prescribed. The cupi^um ammoniatum (in doses of half a grain to a grain twice or thrice a day,) myrrh, and valerian, have received the commendations of Frank and Richter. Aasafattida has been favourably no- ticed by Wolff ; and tartar emetic combined with valerian has been directed by Richter. A combination of assafcetida with myrrh and valerian has also been very generally used by Continental physicians. Dr. Watt has employed the volatile alkali ; and it will certainly often prove an useful adjuvant, combined with other medicines, parti- cularly with opium, or with tonics or diapho- retics ; and be serviceable in combating such nervous or sinking symptoms, as sometimes occur in the course of the disease. It may, moreover, counteract the tendency to the form- ation of saccharine matter, and promote the ani- malisation and assimilation of the chyle, as well as the formation of urea. Even urea itself has been recently tried as a remedy in this disease by Segalas, but instead of changing the mellitic urine, it was found to increase its quantity. Hufeland, and some other physicians in Gf.r- many, have prescribed recent ox-gall in as large doses as the stomach will bear, and frequently with the effect of causing the disappearance of the saccharine state of the urine during its use ; the disease, however, has generally returned upon discontinuing the medicine. 'A7. K. Blood-letting in diabetes had been mentioned as far back as the Commentaries of ARCHiGENEson Aetius ; and it was noticed as an occasional measure by Le Fe vre and Rollo. But it is to Dr. Watt that we are indebted for the introduction of this practice in a most de- cided form. This physician advises full and often- repeated blood-lettings, with the view of arresting the inflammatory determination to the kidneys. This plan has been adopted by Dr. Sattekly and others with manifest advantage, whilst it has failed with some. Drs. Prout. and Hufeland consider it beneficial only in the early and acute stage of the disease. Dr. Ma rsh offers a similar opinion. And my own experience would lead me to employ it, only when the disease is recent, the strength of the patient not much exhausted, and the pulse remains of good strength and volume. When the patient feels much pain in the loins, an additional indication is thereby furnished for resorting to it. Sir David Barry has advised frequent cupping on the loins hi the course of the disease,— a practice which is de- serving of adoption in cases of the above descrip- tion, or when much pain is complained of in that situation. I have found advantage from the ap- plication of a number of leeches on the epigas- trium, and cupping on the hypochondria, Loth in relieving the sense of pain and heat complained of in the stomach, and in lessening the quantity of the urine, and of the saccharine matter con- tained in it. Depletion, as Dr. Watt first ob- served, certainly improves the state of the blood, and renders the weak and imperfect crassamen- tum more firm. 38. L. Blisters and external applications of a derivative and irritating nature have been recom- mended by Ritter, Desault, Van Swieten, Whytt, and Reidlin, to be applied chiefly to the loins and epigastrium. Frank and Weiz advise repeated blistering of the sacrum. Setons, issues, and moxas have likewise been employed in the latter situation ; but I believe without any permanent benefit. The most efficacious modes of derivation are the vapour bath, warm alkaline baths, and thick woollen clothing worn next the skin. Topical applications of a tonic and an astringent nature have also been directed to be kept constantly applied to the loins by Whytt, Reidlin, and Van Swieten. Of these, how- ever, I have had no experience. I have, how- ever, prescribed liniments to this situation, as well as to the epigastrium, generally composed as follows :— No. 165. R Liniment. Camphorae, Olei Terebinth., Linimeu. Saponis Comp. aa ?. j. ; Pulv. Opii Puri ^ j.; Pulv. Capsici Annui 3 ss- > Olei Limonis TTJ xxx. M. Fiat Liniinentuiii, cum quo assidue illinantur regio lun- balis et spina dorsi mane nocteque. I have found this application extremely useful in the excessive discharge of albuminous urine, which is not infrequently met. with in young sub- jects. I have likewise employed it with other means in the mellitic state of urine ; but it was difficult to determine what share of the temporary benefit derived was owing to it. 39. ii. The Treatment in which the Author is most disposed to confide. — It is not easy to form to ourselves precise and rational indications of cure in this disease, particularly as opinions re- specting its nature are not supported by a suffici- ent number of accurately recorded facts ; nor are those which have been observed so constantly present, or so uniformly grouped, as to permit us to draw indisputable pathological inferences, for the basis of therapeutical indications. I shall therefore state succinctly the method of cure, which is sanctioned by my own observation, and by experienced physicians. The remark which has been made by Dr. Parr, Dr. Prout, and others, that this disease should be viewed in a two-fold light — namely, 1st, as respects its sac- charine state independently of the increase of its quantity ; and, 2d, as regards this state in con- nection with an augmented secretion — should be kept constantly in recollection ; and, although the discharge of an increased quantity of urine, in addition to its saccharine condition, generally in- dicates either a more advanced or a more severe state of disease, yet we should be aware that the saccharine change is the more important of the two ; and that ii is much more easy to diminish the quantity than to improve the quality of this 516 DIABETES —Treatment. secretion. Dr. Prout justly remarks, that it is exceedingly doubtful if there be any remedy that exerts a specific action in improving the quality of the urine—at least, there is none at present known. The improvement can therefore be at- tempted only by those agents that have aten- priate means. If, however, doubts respecting the propriety of its repetition be entertained, cupping upon the loins, or upon the hypochondria, or the application of leeches on the epigastrium, according as the sensations of the patient may direct the practice, should be substituted, and dency — 1st, to restore the general health and ' carried to an extent, as respects quantity and assimilative energiet of the frame; and, 2d, to diminish the quantity of the secretion. 40. These ends are generally all that we can reach; and, by attaining them, we sometimes advance still further, and thereby improve the quality also of the discharge. There are, how- ever, other subordinate objects, which, although they might be accomplished with the fulfilment of the chief ends now proposed, yet often require an immediate regard ; and the more especially as their attainment very frequently promotes the chief intentions of treatment. These are — a. To remove a congested, loaded, or oppressed state of the vascular system, and reduce the quantity of the circulating fluid more nearly to a level with the amount of vital power and assimitalive function, b. To promote and improve the secre- tions employed in digestion, and excite the ex- halations and secretions from the respiratory and intestinal surfaces, c. To remove the unper- spirable and harsh state of the cutaneous surface, to increase perspiration: and thereby to lessen the determination to the kidneys, d. To di- minish the morbid sensibility and irritability of the frame, with the other morbid phenomena allied to them. The means which we employ in attaining both the principal and the subordinate objects which I have now stated, will, of course, vary exceedingly, according to the particular features of individual cases, and the constitutional powers of the patient. The previous duration of the disease — the degree of activity it may pre- sent— the age of the patient — the state of the circulation — and the particular condition of the urine, as respects both its density and quantity, should individually and collectively be considered by the practitioner as circumstances calculated greatly to modify the means of cure ; and should weigh so entirely with the judicious, as to lead them to consider even the best practical sugges- tions which can be offered as applicable merely to some cases, and as requiring to be varied, and rendered appropriate to others. It must be ob- vious that we cannot endeavour to attain, seriatim, the ends now proposed ; for a judicious and an active treatment will often fulfil two or more of them contemporaneously. 41. I have already noticed the opinions of Dr. Watt and others (§ 37.) as to blood-letting. In cases of recent occurrence, with an active state of the circulation, and pain in the loins, with much heat and pain in the epigastrium, or where congestion or oppression of the vascular system exists (§ 40. a), I consider general blood-letting, repeated as often as the circum- stances may require, as requisite to fulfil the intention stated above (§ 40. a). The fre- quency of, or even the propriety of repeating, the operation will depend much upon the appear- ances of the blood drawn, and the effects pro- duced by it. If the crasis of the blood be weak — the coagulum being loose, and dark — I have seen no benefit derived from it until the vital energies have been somewhat excited by appro- frequency of repetition, on which the observation of the practitioner will enable him to decide. In protracted cases, when the disease occurs in old subjects, when the debility is great, and the pulse quick, small, or weak, general blood-letting is not productive of benefit. If, even in these cases, much pain, tenderness, or fulness be complained of about the epigastrium, local de- pletion, as now recommended, may be employed in its vicinity. It will often happen that blood- letting—especially general blood-letting—will, at first, either be inadmissible, or of little or no ser- vice ; and yet it will subsequently prove of very great benefit, after the other parts of the treatment have prepared the system for it. This fact should not be overlooked at any period of the disease, even in the most unpromising cases. 42. Immediately after depletion, a complete evacuation of the bowels, either by a dose of castor oil, or by the following pill, repeated ac- cording to circumstances, will generally be di- rected with advantage :— No. 166. R Extr. Colocynth. Co. 5 ss.; Pulv. Ipecacu- anha? gr. iij.; Saponis Caslil. gr. viij.; Olei Crotonii Tiglii ft} ij. M. Fiant Pilulse xij. Capiat binas statim, et repetantur bins quarla quaque hora donee plem) de- jicent alvus. The bowels being freely evacuated by the above means, assisted in more obstinate cases by ene- mata, of which I believe those with from one to two ounces of turpentine to be the most efficacious, a full dose of opium should be exhibited, or of the pulvis ipecacuanhas compositus, or the fol- lowing : — No. 167. R Camphors rasa? gr. v.; Pulv. Ipecacuanha- gr.j., Pulv. Opii s;r. ij. ; Pulv. Myrrhap gr. vj.; Mucilag. Acacia;, vel Conserv. Rosar., q. i. ut fiat Bolus, statim sumendus. After having taken this, the patient may have re- course either to a warm or to a vapour bath, have the surface always well rubbed with the flesh- brush on leaving it, and clothe himself in a warm dress with flannel next the whole of the skin. The opium, or the Dover's powder, or the bolus above directed, and the warm bath, may be re- peated at intervals varying according to the cir- cumstances of the case. The effect of this treat- ment is manifested in the state of the skin, and urine, as well as in the feelings of the patient. But, in cases characterised by much debility and irritability, we must vary the means. Here the sulphate or ammonio-tartrite of iron, or the sul- phate of zinc, or the sulphate of quinine, com- bined with opium and capsicum or camphor, and exhibited either in the form of pill or of draught, will often prove of advantage. No. 16S. R Infus. Rosar. Co ad ■> jss.; Quininae Sulphatu Acidi Sulpb. Arom. Tine. Aurantii. Co. M. Fiat Haustus, ter qua- e;r. ij. ; Zinci Sulphatis gr. ss TT) xx. ; Tinct. Opii tt) xx.—xxx 5 j. i Tinct. Capsici TtJ xx terve in die capiendus. In cases of the same description, Dr Prout recommends an electuary with the carbonas ferrt, and opium, and albumen ovi. I have given the carbonate of iron in the form of electuary, with confection of senna, &c. (seeF. 79. 86. 93.), DIABETES—Treatment. 517 in order to preserve a freely open state of the ] bowels. The combination of tonics and as- tringents, or even of astringents with aperients, is sometimes useful. I have obtained advantage j from the following :— No. 169. R Pulv. Cinchona?, Pulv. Rhei, 5a, 7, ss.; Mag nes. Carbon J}j ; Aqu* Ciiinamom. ", jss.; Confect. Atom. gr. x. M. Fiat Hauslus, his in die suinendus. Vel, No. 170 K Pulv. Ithei, Pulv. Uva? Ursi, aa ^ jss.-. Aqua? Cinnamom. ^ jss.; Confect. Aromat. gr. xij. M. Fiat. Hauslus, bis terve quotidie1 suinendus. The above may also be taken with a full dose of laudanum, when the bowels have been sufficiently acted upon, and the irritability of the system is considerable. In order to counteract this symp- tom, 1 have on some occasions had recourse to the hydrocyanic acid in doses of from one to three minims, in a mucilaginous mixture, or employed it in combination with iron or with zinc, in the state of a prussiate of iron and prussiate of zinc. The following was lately prescribed, and con- tinued for several days, with advantage :— No. 171. R Camphorae rasa? et subacta? gr. xv. ; Oxyili Zinci T, ss. : tere cum Mucilag. Acaci e vel Tra'gaca th. X ss. ; Aqu

^-Roeber ,n M„- seum der Heilk. b. iv. p. 296. - ^(.U-c; ■ f ^ '^ fcc. Glasgow. 1808. - R.tler in / vfela.M> Jmiii, der Piarl. Heilk. b. vx. st. 3. ,.. 145. - * huts, id Ibid. h. xm. .1. 2. p. 128.-.W hae/is, in Ibid. " »■»■ »L S. »'• ^'m ","'€' in Ibid. Jun. IhlO p. 120 -Cullen, Practice of Med W i Th.nson vol. i. p. 313. vol. ii p. 491. - ternar. Medi- ! cal Histories a . Reflections, vol. iv. p. 46.— Blume,.bach, I Med. Biblioth. h. ii. p. 127 —Minroand Durcan, in An- nals of Med. ol. viii. p. 3?8.-A«-«/«» el Gueudeville, Recheiches et Experiences Medicales sur la Diabele.- ucrte, ou la I'hthisurie Sucice. Paris, U03.—P/a e, De vera Ilia- beles Cau-a in Defeclu Assimib.tioitis quajrenda. Goet. 1784. —Metz, Diabelis Observatio. in Disput. Med. lad. Haller, t. iv. Henry Ann of Philosophy vol i. p. 27. ; et Tians. of Med. and Chirurg. Soc. vol. ii p- "9- Wollaston and Mmcet, Philos. Tians. vol. ci. 811 p. 96.—Dupuytren el Tkenard n Journ. deMfcd. ontin. vol. xn. p. S3.—Clarke, in Edin. Med. and Surg. Journ. U'lO. - Bostock, Mem of Med. Soc. of Lond. vol. vi. p. 237., elTransac. of Med. and Chirurg. Society, vol. iii. p. 107.—Money, in hid. vol. v. p. 236.—"Mynster", in Acta Regi'd. t. i p*. 250. — H'.frlavd, in Ibi . vol. ii 2d series, p 43.— Maish, Dublin Hospital Reports, vol iii. p. 480. MM. Vauquelin et Segnta in Magen- ie's Journ. de I'hysiologie, t. iv. p. 356. Pari-, K25. — W. P,cut, Inquiry'into the Nature and Tieatine t of Diaheles, Calculus kc. 2d ed t. i Lond. 1825.—Ro~h<,ux Diclion. de M'd. vol. w.—Heivelc- | en, in Lond. Med. Repos. vol. xix. p. 265. Carter, i. Ibid. vol. xx. p. 390. D. liar.-i/, see Lancel, No. 23\ p. 926.— R. (''enables On Diab., Sic. Fvo. Lond. 1' 25. — lanqnelin et St gal as d'Etchepa.e, in Archives Gener. de.M decine 1 t. vi. p. 625. — Lbst in, in Ibid. vol. xviii. p. 432.: el in R^perl. Gtner. d'Anat. et hvs. vol. ii. p. 356 —Shaikey, in Transar. of Iri,h College of Phvs. vol. iv. p. 379.—SouiV- laud, Diction, de Med. et Chir. Prat. vol. vi. p. 249.—.V. Good, Study of Met!., by Cooper, vol. v. p. 494. ;ee M'mptom atolog y. DIAGNOSIS. DIAPHRAGM (from ■ti,:pe- rienees violent, shaip, burning pain, tension, and cord-like constriction, at the lower part of the thorax, particularly beneath the sternum and hypochoud.ia, and stretching to the loins,— in- creased and descending lower during inspiration —diminished and ascending during expiration,— augmented by coughing, sneezing, fulness of stomach, and pressure on the ; bdon en ; like- wise by vomiting, by the expulsion of the faeces or urine, and by bending the Dunk of the body in any direction. Ihe breathing is short, f,e- quent, anxious, small, and pet formed entirely by the intercostal muscles, the abdomen being nearly motionless. '1 he h\ pochoi diia fill in- wards, or are retracted, and, with the precordia, are sensible to p essure. rl here are frequent'y painful and diflicu t deglutition, referable lo ihe lower part of the oesophagus ard caidia ; great anxiety, with occasional interrupted sighs ; sin- gultus, particularly towaids the close of the dis- ease ; involuntary retraction of the angles of the mouth, or risns sardonicus ; delitiun , which is sometimes furious; spasms, or great feeb'e- ness of the muscles of the ;,bdomen and extre- mities ; irritable, porraceons vomiting ; leipnthy- rnia or sinking, &c. The pulse is always fre- quent— at first strong and hard, afterwards small, more quick, wiry, &c. 'J he bowe's are consti- pated and urine in small quantity ; thi st is at first urgent, afterwards not felt ; and restlessness, par- ticularly iis the disease advances, is extreme. 7. B. Com/ Heated Forms, —a. Ihe symptoms vary considerably with the surface of the organ chiefly a fleeted, and according as inflammation of an adjoining viscus may have preceded, ac- companied, or followed that of the diaphragm. When inflammation implicates the diaphragmatic pleura, or extends to the lungs, mediastinum, or pericardium, we must expect to observe many of the symptoms of those diseases ; paiticularly those consisting of lesion of the funclion of re- spiration. Percussion will give out a sojiiewhat duller sound than natural ; cough will be more or less complained of, and be frequently attended with a watery mucous expectoration. 8. When the inferior surface of the diaphragm is inflamed, the stomach and liver se'dom escape participation in the disease. In this case the pain and sensibility of the hypochondria are in- creased, and the stomach is more severely dis- ordered. When the muscular or tendinous structures are chiefly imp'icated, the con plaint assumes its most violent forms ; and, owing to the nerves of the organ being then more seiious- ly affected, the sympathetic effects of the dis- ease, as delirium, ihe sardonic spasm of the mus- cles of the countenance, singultus, dysphagia, anxiety, retraction of the hypochondria, spasm of the abdominal muscles, &c. are more coustant and severe. $). Diaphragmitis is sometimes complicated with, at other times consequent upon, acute rheumatism ; and I believe that it may be asso- ciated both with inflammation of the convex and ent of Inflammation of. 520 DIAPHRAGM —Tub atm i posterior part of the liver, and with acute rheu- matism, in the same case and at the same time. I am at present attending a patient, in whom there is every reason to infer the existence of this very complicated malady ; and am of opinion that similar associations of the disease would have been more frequently remarked in practice, if the severity of the rheumatic pains, and of the re- mote symptoms caused by inflammation of the diaphragm, had not masked those more directly connected with the affected organ, and thereby misled the practitioner. 10. There are several symptoms which have been adduced by authors as pathognomonic of this malady, but which are not uniformly ob- served : thus, Stoll, Aaskow, and Boissf.au have found delirium frequently wanting altoge- ther : and, in several cases, in which I have seen the disease complicated with hepatitis and pleu- ritis,—particularly the former,—neither delirium, nor the cynic spasm, was present. I agree, however, with J. P. Frank (De Curand. Morb. Horn. t. ii. p. 193.), in considering these symp- toms as being more frequently met with in this disease, than in any other affecting the viscera of the large cavities, and particularly when the ten- dinous part of the organ is affected. 11. C. Course and Termination.—The course and progress of this disease are generally acute. If it terminate not in resolution within a few days, it produces either adhesion to the adjoining vis- cera, or disorganization, followed rapidly by death. When adhesions form, signs of chronic disease of this and the adjoining viscera continue after the subsidence of the acute symptoms ; but when disorganization and gangrene supervene, the pa- tient experiences, after a very few days, a sense of suffocation, sinking, with singultus, extreme frequency and smallness of pulse, faintings, &,c, speedily followed by dissolution. 12. D. The morbid Appearances most fre- quently found after diaphragmitis are, effusions of coagulable lymph, or of sero-albuminous fluid, or of both, on either of the surfaces of the organ, generally with adhesions, more or less extensive, to the adjoining viscera ; increased redness and vascularity, or deepness of colour, of one or more of the different structures composing the organ ; false membranes upon its surfaces ; portions of it ulcerated, or of a dark colour, softened, and nearly disorganized ; and, more rarely, sphace- lated in parts, infiltrated with pus, or containing one or more distinct purulent collections. 13. iv. Prognosis.—Recovery from this ma- lady should be considered as very doubtful, until we have very unequivocal symptoms of resolution, without any sign of the extension of disease to the organs situated on either side of the diaphragm. a. The circumstance of diaphragmitis arising from external injury, or the extension of inflammation from the pleura and pericardium; the early acces- sion of urgent anxiety, followed by delirium; singul- tus, and sobbing ; depressed, collapsed,and anxious countenance, with spasms of the muscles of the face; irregularity, intermission, and smallness of pulse ; coldness of the extremities ; leipothymia; difficult deglutition ; frequent and irritable vomiting, and restlessness; absence of thirst ; convulsions ; con- vulsive, frequent, and laborious respiration, &c; are very unfavourable symptoms, b. The sub- sidence of the urgent symptoms; and improved state of the pulse, and appearance of the coun- tenance ; the occurrence of any of the critical evacuations, or restoration of the suspended secre- tions, or a sound and refreshing sleep ; a more natural respiration, and the absence of serious disease of the colatitious viscera ; are the most favourable circumstances. 14. v. Treatment.—The intentions of cure are the same in this as in other acute inflam- mations. The antiphlogistic treatment promises us the principal aid ; but to be successful, it must be employed early in a decided manner. Full blood-letting from the arm, the patient being in a semi-recumbent posture, until a decided effect ensues — until syncope approaches, but is not induced — as recommended in another place (see Blood, § 64.) ; afterwards cupping on the loins and back, on each side of the spine: leeches applied near the interior insertion Oi the diaphragm ; purgatives; refrigerating diapho- retics ; febrifuge diluents ; external fomentations and cataplasms ; tepid baths; purgative, and sub- sequently emollient enemata, with complete still- ness and silence ; should be employed according to the exigences of the case. The practitioner ought not to be deceived by the presence of sin- gultus, and the great depression of the powers of life so frequently attendant on the disease ; and thus be led to the exhibition of antispasmodics and stimulants, when opposite measures are re- quisite. Nor should he be induced by the state of the stomach, and of the matters discharged from it, to exhibit emetics. When vomiting is present, it should be allayed ; and, for this pur- pose, as well as to prevent the formation of coagulable lymph and adhesion between the sur- faces of the organ and the adjoining viscera, large doses of calomel and opium—from ten to twenty grains of the former, and from one to three of the latter, either with or without from one to three grains oi camphor—should be exhibited, and repeated at intervals of six or seven hours ; the first dose being given immediately after the first blood-letting. Ihe danger of the disease requires prompt and powerful agents; and, after depletions, the combination of calomel, opium, and camphor, is particularly serviceable. 15. When the disease is associated with in- flammation in the adjoining viscera, the calomel should be carried so far as to affect the mouth; and if the pleura or pericardium be also diseased, antimonials and diuretics ought to be added. If the convex or posterior parts of the liver and peritoneum be also inflamed, the use of mer- curials are also required, and with nearly the same intentions, viz. to prevent adhesions, and procure the absorption of effused fluids. If the disease be associated with rheumatism, or gout, then, after local depletions, active mercurial ca- thartics, and derivatives applied to the joints, colchicum, with large doses of soda or potash, or with magnesia, ammonia, or camphor, may be exhibited. 16. It often happens, that after the inflam- mation in this organ and its collatitious viscera is subdued, considerable irritability, evinced by the occurrence of singultus upon taking substances into the stomach, continues for some time. To remove this, the use of gentle tonics, combined with anodynes and antispasmodics, as the infu- sion of calumba, with opium, sub-carbonate of DIAPHRAGM — Organic Lesions of. 521 soda, hyoscyamus, or camphor, is generally re-1 quired, or of the infusion of valerian, or of the oxides of zinc, or the sub-nitrate of bismuth, or musk, &c. Convalescence, and the regimen of | the patient, are to be managed precisely as in other inflammatory diseases. 17. II. Diaphragm, Organic Lesions of. — i. Perforation of the diaphragm is not an uncommon consequence of abscess of the liver, pointing up towards the thorax. In the great majority of such cases, adhesion of the adjoining surfaces of the liver and diaphragm has preceded the perforation ; and, when this has been accom- plished by the disorganising process following the inflammation excited in the diaphragm, the con- tents of the abscess pass either into the cavity of the thorax, or, adhesion of the inflamed diaphragm to the lungs having also taken place, into the lungs, whence it may be expectorated, and the patient even recover. (See Liver — Abscess of the.) Instances have even occurred of the abcess having thus traversed the diaphragm, and opened into the pericardium. 18. Perforation of the diaphragm has like- wise taken place from abscess of the spleen, and from ulcerations of the stomach, which had adhered to the diaphragm. It has very seldom been observed that the perforation of this organ has occurred in an opposite direction, namely, from the thorax downwards. But Portal (Anat. Mid.) met with a case, in which an imposthunie of the lungs opened through the diaphragm, and burst into the abdominal cavity. The diaphragm may likewise be perforated in this direction by aneurism of the aorta. Mkckel also found ulceration of the diaphragm, apparently resulting from chronic inflammation, in the dissection of a maniacal patient. 19. ii. Rupture of the diaphragm sometimes occurs from falls; violent succussions of the trunk ; vomiting, or severe retchings ; blows on the abdomen, back, hypochondrium, or epigas- trium ; suppressed efforts, and sudden muscular exertions. M. Percy states, that a young female, suppressing the pains of child-birth, uttered a plaintive cry, had her mouth hideously distorted, and shortly afterwards expired, giving birth to a child. On dissection, the diaphragm was torn obliquely in the fleshy part of the left side. Two thirds of the stomach, with a portion of the omen- tum and colon, had passed through the rupture into the thorax. On another occasion, M. Percy found, after a fall, the ribs of the patient very prominent ; the abdomen, at its upper part, sunk inwards ; and the countenance presenting the risus sardonicus. He prognosticated a rupture of the diaphragm, which was found after death. (Percy, Diet, de Scien. Med. t. ix. p. 2! 4.) Rupture of the diaphragm is not necessarily immediately fatal. Boisseau (Nosog. Organ, t. ii. p. 623.) mentions a case, where a patient lived six months, and followed his occupations, after the occurrence. A person having taken an emetic, died soon after- wards with convulsions, the cynic spasm of the muscles of the face, &c. On examination, the tendinous part of the diaphragm was found torn near the part where the intercostal nerve passes through it. 20. iii. Various MoIrbid Productions have been found more or less intimately connected with the diaphragm,-in persons who had experienced disorder of the respiratory function. These have consisted of tumours, of various descriptions, en- cysted or unencysted ; cartilaginous or osseous formations, and earthy concretions, in its surfaces (Schreiber, Leveille, Voigtkl) ; fleshy tumours ; and large,/i6rous cysts containing hyda- tids (Portal), or merely an aqueous or serous fluid. It is not infrequently found partially dis- placed in aneurism of the heart and aorta. Castes of this description are recorded by Vetter afd Blancard. Jt is also pressed high into the tho- rax by enlarged or suppurated liver. 21. iv. Spasmodic Actions. The diaphragm contracts forcibly in crying, coughing, vomiting, during the expulsion of the excretions, child- birth, and tenesmus. It contracts slowly, but forcibly, and is rapidly followed by relaxation, in sighing. It contracts for a longer time, and is relaxed more quickly in yawning. The contrac- tion is more rapid, forcible, and interrupted by closure of the glottis, in hiccup, sobbing, &c. ; and sneezing is owing to convulsive contraction of the diaphragm, followed soon afterwards by convulsive action of the expiratory muscles. In all these, the other inspiratory muscles co-operate more or less energetically. 22. The motion of the diaphragm is generally more frequent, irregular, and unequal, than na- tural, in convulsive diseases, particularly when the irritation is propagated to this part, or in- fluences the functions of the parvagum, by being extended to the lop of the spinal cord, &c. This is evinced in epilepsy, hysteria, pertussis, &c. The contractions of the organ are still more dis- ordered in tetanus, they being nearly permanent about the fatal close of the disease. Death is occa- sioned by this, rather than by any other circum- stance ; the permanent spasm of the diaphragm and other respiratory muscles preventing the ex- pulsion of the inspired air, and consequently pro- ducing a variety of asphyxy. (See art. Hiccup.) 23. v. Paralysis of the diaphragm is incom- patible with the duration of life, and can occur only during the last moments of existence. It may be induced by the inhalation of noxious gases into the lungs, and from virulent poisons, thus constituting another form of asphyxy : and it is produced by injuries of the medulla oblongata, or in its vici- nity, or by whatever may interrupt the functions or injure the parvagum. I have met with a case where it followed, at a remote period, fracture by muscular action of the dentated cervical ver- tebra, as verified on dissection by Professor R. Qua in and myself. Bint.ioo. and Kefer. — Galen, De Locis Affect. I. v. cap. 4. — Bonet, Sepulch. Anat. 1. i. sec. i. obs. 1. — Mor- gagni, Fpist vii. art. 14. — Roth, Diss, de Inflammat. Septi transversi. Lips. 1748. — Schulze, Diss, de Paraphreni- tide. Hal. 1742. — Schneider. De Inflam. Diaphragmatis. Wilteb. 1665___Meckel, in Mem. de I'Acad. de Berlin, 1764, p. 88. — Schroeder, Be Inflam. Diaph. Goet. 1772. Stoll, Ratio Med. t. ii. p. 385. — De Haen, Ratio Med. par. i. p. 84., par. ix. p. 17.—L. A. Ebeling, liss. de In- flammatione Diaphragmitis. Goet. 1771.—G. M. Gatten- hof, Spec. Sist. Paraphrenitidis Rationem et Curationem. Heid. 1791. — Isevfamm, Prakt. Anm. tiber die Mus- keln § 162. — Aaskow, in Act. Hafn. vol. i. p. 205.— Sandifort, Exercit. Acad. 1. ii. p. 88. - Portal, Anat. Medical, t. iv. p 233. — Hempel. De Diaph. Sano et Mor- boso. Goet. If03. — J. P. Frank, De Cur. Horn. Morb. I. ii. — Roy. Traite sur le Rire. Paris, 1814. — Sawicz, De Dinphragmitide. Wilna, 1819. — Hildenbrand In- stitutiones Medicae, t. iii. p. 267. — J. Frank, Praxeos Med. Praecep. Univ. par. ii. vol. ii. sect. 2. p. 2. — Boisseau, Nosographie Organique, t. ii. p. 617.— Voigtels, Pathol. AnaLt. ii. p. 201. 522 DIARRHCEA—Idiopathic DIARRHGBA. —Sr*.(J,,,,ri,,, from A.aMfm, I flow through, hit and »*'-). Diarrhoea Ca- catoria, Rheuma Gaslros, Galen. Rheuma- tismus, Alexander of Tralles. Defluxio, (alius Aurelius. Alvi F/uxus, Ventris Profluvium, Auct. I.at. Cours de Ventre, D.'voyement, Fr. Der Durchfall, Bauchfluss, Durchlauf, Germ. Diarrea, Ital. A Purging, Looseness, fyc. Classif.—2. Class, Nervous Diseases ; 3. Order, Spasmodic Affections (Cullen). 1. Class, Diseases of the Digestive Func- tion ; 1. Order, Affecting the Digestive Canal (Good). 1. Defin. — Frequent, loose or fluid alvine evacuations, without tormina or tenesmus. 2. Although diarrhoea may occur as an inde- pendent or unassociated complaint, yet may it supervene as an occasional or even common symptom, in several maladies. Dr. Cullen, whilst he admitted diarrhoea as a specific disease, yet viewed it as always symptomatic of other pathological states. That it is so in most cases, cannot be doubted ; but that it also is, in some instances, an idiopathic disorder, in respect both of its primary manifestation, and of its inde- pendence of inflammatory action of the intestinal mucous surface, or of disease of immediately related organs, is equally certain ; and fully demonstrated by its causes and progress, — by the effects of treatment, and the appearances observed in fatal cases. 3. I. Symptoms and Varieties of Diar- RHceA. — This disease is usually preceded bv various dyspeptic symptoms, sometimes by slight nausea, frequently by uneasiness in different parts of the abdomen, by flatulence, and by pain, par- ticularly before an evacuation takes place. In severe cases, the abdomen is somewhat distended, and tender to the touch, and its temperature in- creased ; and occasionally the stools are preceded by much pain in the tract of the intestines, and accompanied with vomiting, or with faintino- or leipothymia ; they are always without effort, but are rarely involuntary. Each evacuation relieves for a time the patient's uneasiness, which, how- ever soon returns. The discharges are usually copious, offensive, and feculent at first ; but they soon becomes wore scanty, watery, or mucous__ often in proportion to the frequency of the calls to evacuation, after each of which the patient feels more and more weakened. Their number varies from three or four to twenty or thirty in the twenty-four hours, but they are not so often voided in the night as in the day. At the com- mencement of the attack, and in slight cases, the pulse is generally not materially affected ; but when vomiting or much griping pain is present, it is often increased in frequency. At an ad- vanced period it is usually small, weak, and somewhat accelerated ; the countenance bein" pale, the body somewhat emaciated, the strength diminished, and the s'iin dry and very sensibieof cold. The tongue is often loaded from the com- mencement in the middle and at theroot,and some- times is red at the point and edges. The urine is generally scanty throughout the complaint. The evacuations vary remarkably as to the nature of the matters composing them, their colour, con- sistence, smell, and other appearances, not only in different cases, but even iu the same case, at different periods. Nosologists have generally 1 divided the disease into varieties or species, ! founded on the different states of the discharges. But this is not a satisfactory basis of classifi- cation, as the appearances of the evacuations do I not depend upon definite pathological conditions, | although furnishing important indications of the ! seat and state of disease. The most common of these appearances are, the/mt/fn*, which usually precedes the others ; the bilious ; the mucous ; the serous ; the chylous, or whi'.e ; and the lienteric. But every practitioner must have observed that j not only will these discbarges present themselves during 'different periods of the disease, but that two or more of them may co-exist ; thus, the evacuations are not infrequently, at the same time, bilious, mucous, and serous ; or feculent, bilious, and mucous ; or watery and bilious. | i. Idiopathic Diarrhoea.— Classif. II. Class, I. Order (Author). I 4. D k fin. — Copious, feculent, and frequent j evacuations, sometimes preceded by griping, and unattended by fever. 5. A. Diarrhoea of Irritation.—This form I of the disease comprises most of the cases denom- inated feculent by authors, and termed D. Ster- corea by Sauvages, D. Crapulosa by Cullen, | and I). Fusa by Good, (a) It is usually caused by any stimulating or irritating substance re- ceived into the stomach ; by too great a variety or quanity of food or drink, or even by a small quantity of that which is unwholesome, or which may disagree with the p.itient's diathesis, or with the existing state of the digestive organs ; by in- digestible vegetables, particularly cucumbers, melons, salads, &c. ; by various acid fruits, par- ticularly plums, pine-apples, &c. ; bv acidities generated in the prima via, and the quality of the nurse's milk ; and by dentition in infants. — (b) The symptoms in this variety are frequently nausea ; severe giping pains before each evacu- ation ; foul, or loaded tongue ; copious feculent stools, afterwards becoming frothy, watery, or mucous, and exhaling an offensive or sour odour; the pulse and temperature of the surface being but little affected. — (c) This form generally ceases spontaneously, owing to the evacuation of the offending substances ; and the digestive func- tions are soon afterwards restored, if its cause be subsequently avoided. It may, however, excite some of the other pathological states to which this disease has been ascribed, and be thereby pro- longed ; or it may terminate in organic change. 6. B. Diarrhoea of Relaxation associated with Irritation(Diarrha>a a Cibis corruptis, Sennfrt —(a) may be caused by whatever relaxes the tone of the intestinal mucous su face, or of its vessels, by its septic influence, whilst it excites the peristaltic actions of the tube, as stale fish, high game, or any animal food approaching to putridity, over-ripe or decayed fruit, stale vege- tables, &c, and putrid, stagnant, marsh, or running waters containing animal matters or exuvias or vegetable substances in a state of dec mpostion, or of minute division or solution, &c. _ (A) The symptoms are, copious, feculent, offensive, and, in some instances, involuntary motions, becoming scanty, watery, and frothv, and preceded by borborygmi or gurglings in the abdomen —se'dom by gripings or n; usea ; a natural or slightly foul, mucous^slimy, or clammy tongue; diminished temperature of "the surface • DIARRHOEA —Symptomatic. 523 and a soft, weak or a natural, or but little accel- erated pulse. — (c) This variety either ceases as soon as the matters which occasioned it are expelled, or it assumes more severe characters. When it has been produced by unwholesome water, and particularly if this cause continues to operate, it frequently passes into the mucous variety, or into dysentery, or into a chronic state; and sometimes a low remittent form of fever supervenes, terminating in disease of the mucous follicles, and ulceration of the bowels, &c. ii. Symptomatic Diarrhea. — Classif. III. Class, I. Order (Author). 7 Defin. — Frequent, and generally morbid, alvine evacuations, from disease of the bowels or collatitious viscera, often attended by fever. 8. A. Diari~hcea from acrid, or an increased Secretion of, Bile (the D. Biliosa, of authors).— a. Bilious diarrhoea is a very common variety, particularly during summer and autumn, and amongst Europeans who have recently migrated to warm or intertropical countries. It also fre- quently occurs in persons who live intemper- ately, in respect either of eating or drinking ; and in those who are harassed by anxieties or the depressing passions, especially if they be of the melancholic temperament. It may be induced also by violent fits of anger, or other intense emotions : an aperient or purgative medicine may even excite it, if the biliary organs be loaded at the time with morbid or acrid bile, and the liver be in an excited state. It appears probable that irritation of the duodenum, in the vicinity of the common duct, may be propagated to the liver and pancreas, occasioning an increased secretion both of bile and of pancreatic fluid ; and that, whilst such irritation augments the vermicular action of the upper part of the intestinal tube, thereby accelerating the passage of the chyme along it, the quantity or quality of the secretions poured into the duodenum excites the internal surface of the bowels, increasing both their se- v creting and contractile functions.—(b) The evacu- ations in this form of dinrrhcea are at first feculent, and commonly of a green or greenish yellow, or even bright yellow colour : they afterwards be- come more fluid and watery, vary in color, and are mixed with thin feculent matter. If the diar- rhoea continues, they frequently contain yellowish or greenish yellow mucus, either in large thick masses, or in thin, glairy, or gelatinous pieces, which fall to the bottom of the pan, and admit of being drawn into long filaments ; or they consist chiefly of a serous fluid, coloured by the bile, and presenting either a glairy mucus or albuminous flocculi, evidently owing to the irritation caused by the acrid bile having been followed by in- creased vascular action in the intestinal mucous surface, and an excited state of its follicles.—(c) In this case, bilious may pass into inflammatory diarrhoea, in either of its forms, as constituting the two following varieties; or into dysentery. 9. B. Diarrhoea from Determination to, or in- creased vascular Action in, the intestinal mucous Coat—Inflammatory Diarrhoea (the D. Serosa of Sauvages, Good, &c., D. Aquosa, of Hoff- mann).—(a) This variety is caused by whatever occasions a greater flux of blood to the intestinal mucous surface, and a freer exhalation and se- cretion than are natural, by obstructing these functions oa other surfaces: as the application of cold, in any form, to the cutaneous or pulmonary surface, or to both at once; various mental emo- tions, as anxiety, fright, surprise, &c. ; or even the slightest agitation of mind in some consti- tutions; cold acid beverages, or ices, taken when the body is overheated or perspiring ; the sup- pression of chronic eruptions, or copious or accus- tomed perspirations or discharges ; the disap- pearance of abscesses, drying up of old sores, and checked menstruation or lochial discharge.— (b) 1 he evacuations are watery or serous, mixed with thin feculent matter, and exhibit every shade, from a dark brownish, or greenish brown, to a pale, greyish, or whitish colour ; and they con- tain, in some cases, pieces of thick gelatinous mucus, or a thin, glairy and stringy mucus ; in others, whitish albuminous flocculi ; and, in a few instances, large membranous or albuminous shreds or flakes, moulded on the internal surface of the intestine, constituting the D. Tubularis of Dr. Good. The discharges in this variety are often preceded by sickness or vomiting ; by severe griping pains in the abdomen ; and are attended by a dry, harsh skin ; increased temperature of the trunk ; a flatulent state of the bowels ; a small, frequent, constricted, but soft pulse ; a furred or loaded tongue, particularly towards the root, with red edges and point; and scanty, high- coloured urine. Ihe patient also often complains of an aching, dull pain in the abdomen, some- times increased by heavy pressure.—(c) Inflam- matory action may not exist in every case of this variety; or it may not supervene until after siinp!e determination of blood to, or irritation of, the mucous surface has continued for some time ; and, even when present, it does not necessarily occasion the diarrhoea. This variety occurring in infants, constitutes what is usually called the watery gripes (§.15.), and sometimes gives rise to one or more intus-susceptions; or it passes into chronic-diarrhcea, with disease of the mucous and mesenteric glands ; or into slow remittent fever, marasmus, and fatal exhaustion. 10. C. Diarrhaa from excited or inflammatory Action of the mucous Follicles (Catarrhus Intes- tinorum, of various authors ; D. Catarrhalis, of Boerhaave; D. Mucosa, of Cullen, Good, &c; Cceliaca Mucosa, Sauvages). — (a) This form generally appears in the course of function- al disorder of the digestive organs, particularly indigestion, hypochondriasis, costiveness, and colicky affections ; which may be viewed as pre- | disposing to it, by favouring the accumulation of mucous sordes in the follicles and on the internal surface of the bowels ; and is excited by the causes already enumerated, especially those of the preceding variety (§ 9.). It occurs most frequently in old persons, or in those who have suffered from chronic disorders of the digestive organs ; and in children, particularly during the period of first dentition. — (6) The stools often consist entirely of thin gelatinous mucus ; fre- quently, also, of thick mucus, and a considerable quantity of watery or serous fluid; sometimes the mucus is mixed with this fluid and thin fecu- lent matter, or is accompanied with small pellets of far res; and occasionally it has the appear- ance of a semi-transparent mucilage, passing into a muco-puriform matter. The consistence of the motions varies much; and in some cases they are very offensive, but in others without any odour. 524 DIARRHOEA —Relations In many instances they have a greenish or yel- lowish green colour ; in others, an orange or yellow tint: in a few cases, they are nearly co- lourless, or white, and thin, constituting the D. Alba of Hillary; the Fluxus Cceliacus of some writers; the Album Alvi Profluvium of Piso; the D. Pituitosa of Sauvages ; the D. Coeliaca of Cullen; the D. Chylosa, or Lactea, of several authors. These appearances are chiefly attribut- able to the morbid action of the mucous follicles in some part of the digestive tube, most probably in the colon ; to the presence or absence of the biliary and pancreatic secretions ; and to the states of these secretions. This, as well as the preceding variety, may or may not be attended by febrile symptoms, may assume the acute cha- racter, and may pass into the chronic form, the mucous discharges in this latter case often pre- senting a light, whitish, or muco-puriform appear- ance.—(c) When mucous diarrhoea continues for some time, or becomes chronic, it occasions emaciation ; a dry, harsh, or foul skin ; and, in children, gives rise to marasmus, disease of the mesenteric glands, &c. When it becomes chronic, the stools sometimes assume a whitish, or muci- lage-like, or greyish appearance, evincing the ab- sence of bile; or they pass into a muco-puriform state, occasionally streaked with blood ; or they contain long whitish shreds, or threads ; and consist either altogether of these matters, parti- cularly if the disease be seated low in the large intestines, or of an admixture of thin feculent matter with them, particularly when the upper portions of the colon and termination of the ilium are affected. In some cases of this form, occur- ring during difficult dentition, or after the use of calomel or mercurials, or upon the suppression of ptyalism, the stools have consisted of a thin, ropy mucus, of a translucent hue, and have seemed to be chiefly augmented pancreatic secretion. In children especially, when mucous diarrhcea has assumed the chronic form, the evacuations often present the chylous -or milky appearance just no- ticed,— the Chylous Diarrhcea of Devvees and others. This state is attributed by them to the presence of chyme, or imperfectly elaborated chyle, which the lacteals refuse to absorb ; and to the absence of bile: to which causes it is very probably partly owing, as well as partly to the morbid secretions of the mucous surface and follicles. Whatever appearance this variety may assume, it is frequently followed by the next. 11. D. Diarrhoea from Ulceration of the mu- cous Follicles—(a) occurs either consecutively of the two foregoing varieties, or in the course of several febrile or chronic diseases; in which cases, however, it is very often preceded by serous or mucous evacuations, or by both. But ulcer- ation may take place without any such indi- cation, and without the bowels being much, or even at all, relaxed.—(b) The stools are usually muco-puriform, streaked with blood ; sometimes containing shreds or threads of albuminous mat- ter ; and mixed with thin, watery faeces, parti- cularly when the disease is seated in the small intestines or caecum. When the large intestines are chiefly affected, the muco-puriform discharges may contain little or no feculent matters ; or these matters may form distinct portions of the stools, or may consist of detached pellets. In and Manifestations of. some instances, the stools have been very dark, grumous, watery, and foetid ; and, occasionally, merely thin, serous, or mucous, or both, varying in colour, and more or less feculent and oflensive; and yet ulceration has nevertheless existed. In rarer cases, they have been quite black, grumous, and melanoid; or resembling ink, probably from the admixture of blood exuded in the small in- testines, and changed by the action of the secre- tions— whether healthy or morbid. — (c) In this variety of diarrhcea, the emaciation becomes ex- treme, and the skin assumes a dry, harsh, foul, or lurid appearance. The pulse, in its latter stages, is quick, small, and weak. Aphthae sometimes appear on the lips and tongue; and hectic fever, with exhaustion, prevails. 12. E. Diarrhaeawith the Discharge ofunalter ■ ed Ingesta; Lientery (/tfnvrtniu, Gr.; Lubrici- tas, vel Levitas Intestiuorum, I at.; D. Lienterica, of Cullen; the Lienteria of Sauvages and others)—(a) occurs more frequently, in children, before the period of the second dentition, than at later epochs ; and it is generally the consequence or sequela of inflammatory irritation of the diges- tive mucous surface, and disease of the mesenteric glands—of the advanced stages of these patho- logical states. It is most common during the first dentition, particularly when the canine and molar teeth are about to appear; and, in this class of patients, as well as in adults (in which latter it is comparatively rare), it either follows dysentery, or is a concomitant of the last stages, or chronic states, of one of the preceding varieties — commonly of the serous or mucous — than a primary form of the disease. It is caused by the ' same remote agents which induce these its primary conditions; and it evidently depends upon a simi- lar state of increased peristaltic action, and defi- cient vital function, of the stomach and duodenum, to that which obtains in the intestines ; the food being thereby propelled onwards before it has undergone the changes usually produced by these organs, and discharge from the bowels but little altered from the condition in which it passed into the stomach.—(b) The appetite is usually vora- cious in this variety, particularly in children, al- though the emaciation and debility may be extreme. The biliary secretion is also deficient or vitiated; and, in some cases, it appears nearly or altogether wanting in the stools, owing rather to the weak or imperfect action of the liver, than to obstruction. —(c) It usually terminates in stupor, and death from exhaustion ; although recovery sometimes takes place when it is early and judiciously treated. 13. II. Of certain Relations and Mani- festations of Diarrhoea.—i. The Causes of this disease have been noticed in the description of its different varieties. — (a) Diarrhcea is most frequent in childhood, particularly during denti- tion, and in persons of a weak constitution and lax fibre ; and in those addicted to spirituous liquors. I have observed a tendency to it in some families—sometimes in all the children of a family, one of the parents being possessed of the same liability.—(6) It is endemic in some places, evidently owing either to their humid, close, and miasmal situation, or to an impure state of the water, especially in large cities or towns ; or to the nature of the food in common use.—(c) The epidemic prevalence of diarrhoea DIARRHCEA —of Inf ants and Children. 525 has been noticed by Bartholinus (Hist. Anat. cent. ii. his. 65.), Sydenham (Opera, p. 160. 209.), and Leichner (De Diurrh. quadam Epid. Erf. 1676.); and, in some summers and autumns, its frequency has been so great, within my own experience, especially in children, as to justify me in stating that it sometimes assumes this form.—(d) It has also occasionally put on a periodic character, particularly when it has arisen from endemic causes, and been connected with a masked or latent intermittent. It has appeared monthly, in females whose menstrual discharges have been suppressed, — and thus constituted a substituted evacuation. 14. ii. Puerperal Diarrhoea may occur either very soon, or a few days, after delivery. It is occasioned by a neglected state of the bowels previously — by the irritation of collected faeces, or by the irruption of morbid secretions into the intestines. When it proceeds from the former cause, the evacuations are feculent, lumpy, offen- sive, and attended by some degree of tenesmus ; when from the latter, it is often accompanied with sickness, or vomiting, and sometimes with cramps of the lower extremities ; the stools being foetid, bilious, dark green, or greenish yellow, with whitish flakes floating in them. It may be con- nected with suppression of the lochia, or of the milk ; but, in such cases, it is rather the cause than the effect of the suppression. It commonly originates in one of the states of disorder now mentioned, or in both. When, however, such a degree of irritation of the bowels is produced, as will be followed by excited vascular action, sup- pression of either the milk or lochia, or both, may follow, with more or less febrile commotion. Cases of this description usually do not super- vene until a few days after parturition ; and are attended by the phenomena of serous or inflam- matory diarrhcea, with disordered biliary secre- tions, offensive dark stools, with albuminous whitish flakes or flocculi, quick pulse, and symp- tomatic disorder of various functions, favoured by the puerperal state. The more strongly marked cases of this form of disease pass into and constitute what has been termed Intestinal Fever by Burns and others. (See Fevers of the Puerperal State.) The slighter cases even not infrequently terminate in chronic inflamma- tion of the intestinal mucous surface, with all the symptoms of mucous diarrhoea, or of ulceration of the follicles, or of dysentery. 15. iii. In Infants and Children, diarrhoea is remarkably frequent,—especially from the com- mencement of dentition, or the time of weaning, to the third year of age; and is, in respect both of its phenomena and of its contingent effects, a most important disease. These states of it which are identical with those generally observed in the adult, have already been noticed, particularly the serous, mucous, and lienleric.—a. The first of these, in the form of watery gripes, may appear previously to the period of dentition ; and then it is connected with the state of the nurse's milk, or too early or over feeding, which induces acidity of the prima via ; with either inflammatory ex- citement of, with augumented seretion from, the mucous surface, or increased and irregular action of the muscular coat, or both. In either case, the disease may be very acute—may run on to unequivocal inflammatory action, and may occa- sion introsusceptions, with scanty, dark, watery, or mucous and bloody stools, terminating in con- vulsions and death ; or it may be prolonged into the chronic state, owing either to neglect, to the continuance of the causes, or to injudicious treatment. When it lapses into this state, the evacuations become very offensive, watery, of a dark green, brown, or curdly appearance ; are preceded by severe griping ; and are voided sud- denly and violently, frequently with much flatus and straining. In these cases, there are also more or less febrile symptoms ; and, in its advanced stage, often a raw or aphthous state of the mouth ; the disease assuming the lienteric form, or occasioning rapid exhaustion. In such cases, morbid secretions, and knotty or curdly faeces, frequently are retained about the sigmoid flexure of the colon ; and fatal cases generally present the termination of the ilium, the caecum, and lower part of the colon, more or less changed in structure ; or exhibit, along the greater part of the digestive canal, the appearances usually con- sequent upon inflammatory action of the mucous surface. 16. fi. Diarrhcea is also very common in deli- cate children, at the period of weaning; and, in many cases, is connected also — although not necessarily—with the irritation of difficult denti- tion. It usually assumes a chronic form ; and is most severe and most rapid in its progress in infants who have been much too early or ab- ruptly weaned, and improperly fed at the time, or afterwards. This form of diarrhcea was de- scribed very minutely by Dr. Cheyne, under the term " Atrophia Ablactatorium," or "Weaning- brash;" and afterwards by Cru veilhif.r, An- dral, and others. The evacuations are usually greenish, watery, or slimy; sometimes ash-co- loured und lienteric ; and attended by griping pains, often by retchings and vomiting, with symptomatic, fever. The appearance of the stools, however, varies very remarkably; but they gene- rally partake more of the serous, bilious, or lien- teric characters, than of any others: thereby indi- cating, what, indeed, is displayed on dissection, namely, the inflammatory nature of the disease, and its extension along the alimentary canal, and even to the liver. It usually occurs during sum- mer and autumn, particularly when the seasons are moist and hot; and is seldom of shorter duration than four or five weeks, or longer than three or four months. It is evidently a milder grade of the same pathological states which give rise to the disease I have described under the name of Choleric Fever of Infants: and, although it is connected in its advanced stages with inflam- matory action, yet it is very probable that the inflammation is of an asthenic kind ; and that it originates in irritation produced by acrid and morbid secretions, and by imperfectly digested aud improper food, or by an unhealthy state of the nurse's milk. It is attended by great ema- ciation and debility, and frequently terminates in fatal intus-susceptions, convulsions, or coma from exhaustion, or serous effusion within the head, or from both. 17. y. In rarer instances, a peculiar form of di- arrhoea occurs after weaning, in which the stools are not so very frequent or abundant, but they are pulpy or semifluid, of a clayey colour, and very offensive ; and accompanied with an abun- 526 DIARRHCEA —Associations, etc. of. dant secretion of pale, ammoniacal, albuminous, and foetid nrine, — both the stools and urine emitting a nearly similar smell. The abdomen is full and soft; the skin generally cool ; the mouth, lips, tongue, and fauces are red ; and the debility great: emaciation rapidly follows ; and, in some cases, the bones yield from the absorp- tion of the phosphates which are probably car- ried off by the urine ; the disease partaking as much of the characters of diuresis, or albuminous diabetes, as of diarrhcea. A bilious form of diarrhcea may also occur as a symptom of inci- pient disease of the membranes of, or effusion into, the ventricles ; or irritation about the origin of the nerves. 18. iv. The Dark Races of our species, partic- ularly the negro, are much more liable to diar- rhoea than the white ; and in them it usually as- sumes a chronic state, and frequently the mucous form. It also very commonly presents asthenic characters, is often complicated with intestinal worms, and is prone to pass into dysentery, or to be followed by rapid depression of vital power. 19. III. Associations of Diarrhcea.—(a) This affection may attend the commencement of dangerous maladies, particularly fever, dysentery, pestilential cholera, hepatitis, meningitis, &c, ow- ing to irritation of the mucous coat of the intestines, to the flow of morbid or acrid secretions into them, &c, the evacuations being feculent, bilious, mu- cous, or serous. — (b) Its occasional association with gout has been noticed by Sydenham, Bag- livi, Musgrave (De Arthrit. Anom. cap. 4.), and Lorenz ; and has given rise to the D. Arth- ritica of Sacvages. in children it is very often complicated with bronchitis, especially during den- tition. It may constitute a serious, or even dan- gerous, complication in low remittent or continued fevers, in scarlatina, small-pox, measles, hepatitis, &c.; and may proceed either from determination of vascular excitement to the abdominal viscera, particularly the intestines; or from inflammation, ulceration, &c. of the mucous coat in some part of the canal, especially after retrocession, or re- pulsion of the eruption in the exanthemata ; the stools being serous, dark-coloured, with whitish flocculi or flakes, or mucous, and sometimes bi- lious. It is also often associated, in its chronic states, with mesenteric disease and worms.—(c) It may be critical in several febrile and inflamma- tory diseases; the discharges being bilious, homo- geneous, &c. (See Crises, § 8.)—(d) It is also frequently colliquative, or the result of ex- haustion of the constitutional powers from pro- tracted disorganizing disease — as pulmonary consumption, chronic abscesses, diseased joints, hectic fever, and morbid states of the blood, caused by the absorption into it of purulent or o»her matters generated in any part of the body. In such cases, it more directly depends upon dis- ease affecting particularly the mucous follicles, the tone or vital cohesion of the mucous surface and vessels supplying it being diminished; and the evacuations being mucous or muco-puriform, or serous and grumous, or sero-puriform and partly feculent. Colliquative diarrhcea is also fre- quently dependent upon ulceration, apparently commencing in the follicles, and often without any evidence of antecedent inflammatory action, at least of a sthenic kind. 20. IV. Duration, Termination, and Ap- pearances on Dissection. — A. Diarrhcea, particularly in its idiopathic state, is generally of short duration; but bilious and mucous diarrhcea may be much longer protracted. 1 have seen the former continue, in a warm climate, for several months ; and, in this country, nearly as long, sometimes with short remissions. 1 he serous and mucous varieties often assume an acute character, in respect bolh of intensity and duration ; but they frequently also, particularly the latter, degen- erate into the chronic form ; either retaining their specific distinctions, or assuming those of ulceration or lientery. When the disease has even been cured, there generally remains during life a liability to its return, particularly when it has passed into the chronic state, and has possessed the mucous character. A slight diarrhcea may continue the greater part of life, and at last pass into dysentery.* 21. B. Diarrhcea may terminate—(«) in dys- entery, from an increased affection of the large bowels, frequently connected with inflammatory action or ulceration of their mucous surface and follicles, and spasmodic action of the lower part of the colon : (6) or it may run into enteritis, or even peritonitis, particularly when it commences in the serous form, owing to the extension of in- flammation from the internal to the more external coats of the intestines ; or to the perforation of them by ulcers ; and it may end in abdominal dropsy : (c) or it may give rise to convulsions, to inlus-susceptions, particularly in children: and (d) it may assume the chronic form, varying in severity and duration, and occasioning mesen- teric'disease, emaciation, and exhaustion ; and it may be prolonged even for years, with irregular remissions and intermissions. 22. C. The appearances on dissection can be ascertained only in severe or chronic cases, or in those who have died of its complicated states; or of some other disease on which diarrhcea had supervened, or with which it was associated. In some recent or slight cases, the mucous coat of the intestines has been found quite pale and blood- less; and the follicles, only, more developed than usual. In others, it has been somewhat softened, oi merely injected; occasionally it has been con- gested and discoloured, the injection or congestiop generally existing in patches or streaks, between which it has been quite pale. In more chronic and severe cases, it has likewise been pale, anae- mic, and softened; in some, inflamed, congested, and of every shade, from a rose tint to a brownish or purplish colour—commonly in streaks or patches. In some instances, either without, or in addition to, these and other appearances about to be no- * Some years ago, I was consulted by a well-known and eminent person pa t the middle age, of the sanguine tem- perament and plethoric habit of body, :ind a rigid water- i rinker, who had always had diarrhoea—at least for twenty years. He was directed to be blooded ; and the diarrhoea was moderated merely, without being checked, when it be- came unusually troublesome, as apoplexy was dreaded, and as he was . therwise in excellent health." Soon afterwards, he went to South Ameiica where the diarrhoea passed into acute, and, afterwntds, chronic dysentery, which reduced him, from a full and almost corpulent habit to a stale of extreme emaciation In this slate he met with a dangerom accident, from which he lost so much blood that he rallied with difficulty He recovered, nevertheless: the dysentery w s cured; and the clianhoea upon mv seeing him again in London some years afterward*, had no't returned. DIARRHCEA — Diagnosis — Prognosis. 527 ticed, the mucous and submucous tissues have been oedematous, thickened, and very much soft- ened. Inspissated mucus, or even coagulable lymph, and more frequently a thin, brownish or greyish, or puriform mucus, have been found covering the diseased surface. In some cases of children, the intestines have become soft, white, almost diaphanous, and easily torn ; and have contained a purulent, custard-like matter. Their calibre, in a few instances, has been greater than usual ; but much more frequently diminished, or even much and irregularly contracted, particu- larly in the part chiefly affected. In some in- stances, small pustules containing purulent matter have been observed, apparently unconnected with the follicles; and, upon breaking, have left merely a slight, superficial, and reddish ulceration, or excoriated-like surface (Bright and myself). Both the small and large intestines have occa- sionally presented one or more introsusceptions —sometimes a number, especially in infants and children; and, in fatal cases, soon after weaning, softening, with or without inflammatory appear- ances, has often also existed in the stomach and liver. The intestines have been, in some instances, of a darker hue than natural, externally as well as in- ternally ; either in large portions, or throughout, and occasionally in thickly disseminated dots or points. The mucous glands, particularly in severe or chro- nic cases, and those belonging to the mucous and lienteric varieties, have been very generally found either prominent, enlarged, inflamed, or the seat of ulceration, or of a dark or blackish colour, by Brunner, Stark, Lieutaud, Bang, Aber- "crombie, Bright, Andral, Annesley, and myself. Fungoid ulcers in the situation of the fol- licles, often with prominent and inflamed bases, have likewise been observed by these writers. Brunner(Z3« Gland. Duodeni, fyc.) noticed their prominent and enlarged state in the duodenum; and Stark (Klin. Bemerk. fyc. p. 7.) principally in the large bowels. I have often observed them enlarged, or otherwise diseased, in the former of these situations, in cases of the lientery and atro- phy of children ; but those of the caecum, of the termination of the ilium, and of the colon, are more frequently affected in this class of patients. The mesenteric glands are often inflamed, or en- larged, or indurated, particularly in young sub- jects, and in chronic and lienteric cases. The gall-bladder sometimes contains greenish bile ; and the liver is occasionally more vascular than natural. The parts most commonly or most severely diseased are the ilium, especially its lowest, third, and the caecum. The absence of any appreciable lesion in some cases, and the slight nature of those observed in others, militate against the doctrine of Broussais as to the uni- versal dependence of diarrhcea on inflammation of the intestinal mucous surface. He, however, contends that the blood had retired, in such cases, from the inflamed capillaries into the veins, at the time of, or after, death ; thereby leaving no traces of inflammation observable on dissec- tion. This change may occur in vessels that are simply excited, or after erethism merely of the mucous coat (states most frequently attendant upon slight diarrhcea) ; but not when inflam- mation has actually existed. (See Digestive Canal —Pathology of.) 23. V. Diagnosis. — (a) Diarrhcea is dis- tinguished from dysentery by the tormina and tenesmus ; the scanty, mucous, and bloody eva- cuations; and the more early and marked febrile symptoms, of the latter. In it, the calls to stool are almost incessant and abortive, and the mo- tions are nearly destitute of faeces, or sometimes contain scybalae. In the former, the griping pains, even when most severe, never equal the tormina of dysentery ; of which the distressing tenesmus, the quick pulse, the increased frequency of the calls to evacuation during the night, the presence of strangury, are also pathognomonic.— (b) Diarrhoea differs from cholera, in the much less severity of attack; by the absence of spasms of the extremities ; by the entire absence, or oc- casional occurrence merely, of nausea or vomit- ing ; and by the milder character and less rapid progress of the former. Bilious diarrhoea, how- ever, is sometimes merely a slighter form of bilious cholera ; the existence of spasms in the latter constituting the chief difference, excepting as to grade: and pestilential cholera very fre- quently commences in some one of the com- mon forms of diarrhoea.—(c) Diarrhoea differs, in certain of its varieties — especially the fourth, fifth, &c. — but little from inflammation of the internal surface of the intestines, excepting as respects the activity or acuteness of the affec- tion, and the extent to which the constitu- tion sympathises with the local disease. But although certain states of diarrhoea are chiefly owing to inflammatory action, still this action is attended by increased exhalation and secretion from the mucous surface, wllilst inflammation, either limited in extent, or of a low grade, may exist in this situation, and particularly in the follicles, without the alvine evacuations being either frequent or increased, and even in some instances they may be constipated. It is chiefly from the quickness of the pulse, and the evening accessions or exacerbations of fever ; from the sensations of the patient on pressing and examining the abdomen ; from the temperature and state of the skin, particularly in this situation ; and from the whitish, furred, or reddish appearances of the tongue, and the state of the discharges ; that the existence of inflammation of the mucous surface or follicles of the intestines, in diarrhoea, or inde- pendently of diarrhoea, can be inferred. 24. Ihe Prognosis—(a)oCidiopathic diarrhcea is generally favourable : it is usually slight, and soon subsides after the removal of the offending cause. There are, however, few disorders that will be more readily aggravated, or converted into a more serious disease, by injudicious treatment. —(b) The symptomatic varieties of the complaint are to be viewed entirely as respects the patho- logical states which occasion them. The serous and mucous forms, especially when they assume the chronic state, or occur in children after wean- ing, should always be considered as serious affec- tions, and a cautious prognosis ought to be given. The varieties referred to ulceration, and to the appearance of undigested substances in the stools, are very dangerous diseases, requiring the most judicious medical treatment and regimen ; and, even.with these advantages, the larger proportion will terminate fatally. — (c) The complicated states of diarrhcea, unless those attending the commencement, or marking the crisis, of diseases, are all more or less serious or unfavourable, espe- 528 DIARRHCEA—Treatment. cially colliquative diarrhcea. The degree of dan- ger they portend is particularly noticed in the articles on the maladies with which they are most commonly associated. In all the forms and states of this complaint, the causes, the effects of pre- vious treatment, and the constitution, the habits, and existing state of the patient, ought to be care- fully considered before we form an opinion of the ultimate issue. 25. VI. Treatment.—i. Of Idiopathic Diarrhcea.—A. The Feculent form, or Diar- rhoea of Irritation, when recent, requires demul- cents or diluents merely, in order to facilitate the discharge of acrid or accumulated matters. This having been accomplished, disorder soon ceases. But the irritating substances may be partly retain- ed, and keep up a prolonged, or remitting, state of disease, with griping pains and scanty stools, which may be partly feculent, mucous, or serous— the latter predominating when the irritation is con- siderable. In this case, much discrimination is requisite in selecting the aperient which is obvi- ously required; for, if it be insufficient, the disorder will be prolonged; if it be too active, either super- purgation or inflammation will be occasioned. In such cases, a moderate dose of fresh castor oil; or the compound infusion of senna with manna, tar- trate of potash, and an aromatic, sometimes with tincture of hyoscyamus; or, when the stomach is not irritable, rhubarb with magnesia and a grain of ipecacuanha, in aqua pimentae, &c, will generally have the desired effect. In some circumstances, five or six drops of the tinct. opii, in the aperient j draught, will both moderate its operation, and j render it more effectual. If hyper-catharsis be occasioned by the purgative, a full dose of lau- ' danum, or from one to two drachms of the old paregoric elixir, with external warmth, &c, will soon calm the irritation. When the bowels have been previously constipated, and there is any ten- sion, or hardness, or fulness of the abdomen ; or when the stools are partly faecal and partly mu- cous, or dark-coloured, serous, and muddy ; a mild purgative, such as already advised, will be necessary. The practitioner should take into consideration the habits of the patient as to exer- cise and modes of living, and every argument for or against the existence of accumulated faeces in the bowels, and be thereby guided in his practice. When he observes sufficient indications to warrant the exhibition of a purgative, the effects produced by it, the persistence of the irritation, and the state of the abdomen and of the evacuations, will influence him as to the propriety of repeating it, or of prescribing other medicines. If the first purg- ative have not produced a satisfactory effect, if there be no tenesmus, and if the stools are not very mucous, it will generally be advisable to give a full dose of calomel and of James's powder at bed-time, and either of the purgative doses already noticed early in the morning When this form of diarrhcea appears to have arisen from acidity in the prima via, particularly in children, with green, spinach- like, or knotty or scybalous evacuations, a full dose of calomel, or hydrarg. cum creta with mag- nesia, or magnesia only in anise-seed water, fol- lowed by ctistor oil, will generally be effectual. 26. B. Diarrhoea from Relaxation, or from the septic and irritating operation of the injurious in- gesta, either solid or fluid, mentioned above (§ 6.), requires demulcents combined with aromatics, particularly the confect. aromntica, capsicum, and other hot spices. If the action produced by the offending substances on the bowels have been suflicient to have procured their complete dis- charge, this mav be all that is necessary. But if we suspect, from the associated phenomena, that a part of them has been retained, the treat- ment now advised for the removal of fecal mat- ters should be adopted, with the addition of the aromatics and restoratives just mentioned, in quantity proportionate to the urgency of the case. In cases of diarrhcea arising from putrid matters, capsicum is almost a specific, especially when it is occasioned by fish: burnt brandy is also bene- ficial in these, after the offending matters have been expelled. When either of the foregoing varieties passes into the chronic state, the same treatment will be requisite that is recommended for the chronic mucous form of the disease (§ 30, 31.). 27. ii. Of Symptomatic Diarrhea. — A. The Bilious variety should be treated with strict reference to the presence of griping pains, and the colour of the stools. In this disorder, calomel has been much too indiscriminately prescribed. In every case of it, the existence of pain or of heat about the region of the liver, about the shoulder blades, &c, or of fulness in the epigas- trium, should be ascertained ; and, if these exist in any degree, the treatment should be com- menced with blood-letting, or cupping, or leeches on the praecordia or hypochondria An excited state of the substance of the liver maybe present, without any increased frequency of pulse or heat of skin; therefore the absence of fever should not prevent the adoption of depletion, which may even be repeated. Next in importance to deple- tion, is the use of demulcents, lubricating infu- sions, or diluents with nitre and sub-carbonate of soda, and small doses of antimony, or of camphor, particularly if the papillae of the tongue be erect, and the stools are not offensive, nor dark or greenish coloured. If they be either, or both, and if the tongue be foul, a full dose of blue pill, or hydrarg. cum creta, may be given, and fol- lowed by castor oil, or any other purgative already mentioned, or by the medicines of this kind in the Appendix (F. 96. 205.430.). When the bile, from either its acridity or its quantity, occasions much irritation, the rectum becomes often excited to spastic constriction, thereby preventing the dis- charge of faecal and more consistent matters, and occasioning tenesmus, or superinducing dysentery. In order to prevent this, or to remedy it at its commencement, the refrigerating demulcents just noticed may be associated, or alternated, with cooling laxatives, and the retention of the morbid secretions in the colon guarded against, and their irritating properties diminished by emollient ene- mata. The too early exhibition of astringents or opiates is often injurious in this variety ; for, although they may afford relief for a few days, and the patient may think himself cured, yet he will soon afterwards complain of uneasiness in the abdomen and region of the liver, with fever, foul or furred tongue, and all the symptoms of hepatic disease, which may be soon followed by inflam- mation of the substance of the liver, or dysentery. When we suspect that the diarrhcea has been in- duced or kept up by irritation in the duodenum, the treatment above recommended is quite appro- DIARRHCEA — Treatment of Serous and Mucous. 529 priate; and the refrigerants already prescribed, with demulcents and a mild and low diet, should be continued sufficiently long to take effect. Bil- ious diarrhoea may accompany difficult dentition; and in this case, lancing the gums, and the treat- ment advised in that article, should be adopted. 28. B. Diarrhoea from Vascular Excitement, or Serous diarrhcea, should be treated with refer- ence to the cause which produced it. — (a) If it have arisen from the irritation of morbid matters, and if the symptoms indicate their partial reten- tion, laxatives or mild purgatives are requisite ; but it will not always be safe to exhibit them un- til general or local depletions, especially leeches applied to the anus, warm baths or fomentations, and demulcents with refrigerants, have been employed. Any of the mild purgatives recom- mended above, or F. 790., may be afterwards exhibited, and their action promoted by demul- cent and aperient enemata.—(6) When, however, neither faecal nor other injurious matters are re- tained, "depletions should be accompanied with, and followed by, the internal exhibition of the nitrate of potash, with sub-carbonate of soda, and tincture of hyoscyamus (F. 838.), or tinct. opii comp. (F. 729.), or the paregoric elixir, in demulcent vehicles (F. 728. 866.); and, if nausea be not present, with vinum ipecacuanhae. —(c) When this form of affection arises from checked perspiration, diaphoretics, diluents, the warm bath, a warm bed, and mild, demulcent or farinaceous diet in small quantity, will gene- rally remove the disorder in a very short time. If it be attended by any heat of skin, or accel- eration of pulse, the liquor ammonia? acetatis, nitrate of potass, and camphor julap (F. 865. 871.), will be of much service. — (d) If the motions be frothy, or emit a sour smell, the chalk mixture with ipecacuanha and opiate, or aromatic confection, will be requisite ; and if griping pains with tenesmus be complained of, the pulv. ipecacuanhae comp. with sub-carb. of soda, mucilage, oleum anisi, and aqua pimentae, may be given ; or the old paregoric elixir (F. 728.) in chalk mixture, and assisted by small emollient and anodyne clysters.— (e) These will generally soon remove the complaint; but when it has become more chronic, or is very severe at the outset, or is attended with tenesmus, or seems inclined to pass into dysentery, from eight to twelve leeches, in addition to the previous deple- tion, should be applied close to the anus, and repeated if necessary, the medicines now recom- mended (d) being also exhibited in a more decided manner.* In this form of diarrhcea especially, little or no food should be allowed, excepting the * This form of diarrhoea is very common in persons ad- dicted to the use of spirituous liquors; and it is, in them frequently attended by vomiting, and severe inflammatory symptoms referrible 10 the duodenum, and by chronic disease of the biliary apparatus. A case of this descrip tion, in a married female of good circumstances, was seen by me, in consultation with an able practiti ner, whilst this sheet was in the press. She had, in addition to the above complication, long complained of difficult and very scanty menstruation; this evacuation being waterv, and of a "greenish colour. She had been blooded locally, and very judicio> sly treated. As the return of this discharge was expected, and taking into account the previous treat- ment, the following were prescribed; the borax chiefly on account of the scanty catamenia: — No. 174. R Hydrag. cum Creta gr. iv.; Pilul. . Saponis cum Opio gr. v. ; Syrup. Simp. q. s. Fiant Pilulae ij. omni nocte capiendas. No. 175. R Sodae Sub-boratis g j.; Aqua; Funiculi lighter farinaceous articles, as sago, arrow-root, rice-gruel, tapioca, &c. When the complaint has subsided, and the appetite become craving, or when much irritation of the lower bowels exists, chicken, veal, or mutton broth, may be taken ; and the same articles, after having been strained, may also be exhibited in clysters. 29. C. Diarrhoea from Disease of the Mucous Follicles — Mucous Diarrhoea. — (a) Emetics have been recommended in diarrhoea by Hippo- crates, Celsus (lib. iv. cap. 19.), Pichonet, Fontaine, Sy denh am, Ban G,and VoGiL;but it is in this variety that they are most serviceable, particularly in its more recent states. In it, also, purgatives are required more than in any other. Ipecacuanha is the most appropriate emetic, and small doses of it will likewise be advantageously conjoined with the purgatives or other medi- cines prescribed. I have usually directed, if the disorder was not removed by two or three doses of the more common purgatives, equal quantities of the oleum ricini and ol. terebin- thinae to be taken on the surface of a suitable vehicle, each alternate morning ; a dose of ca- lomel or hydrarg. cum creta, sometimes with Dover's powder, having been given the preceding night, if tenesmus was not complained of; and although this practice has been pursued by me in some hundred instances in the Infirmary for Children, besides occasionally in adults and in private practice, I have never been disappoint- ed in its effects. If, however, it does not very soon remove the disorder, we should suspect the existence of inflammatory action, and have recourse to local depletions, particularly from the anus, to warm baths, fomentations, rube- facient cataplasms or blisters on the abdomen, and a repetition of the alteratives and refrigerants already advised. After morbid or accumulated matters have been removed, and the mucous follicles excited by these medicines to a more healthy action, aromatics, cretaceous powders or mixtures, and the pulvis ipecacuanhae com- positus, or small doses of opium or the paregoric elixir, may be prescribed. Care should be taken not to exhibit astringents or opiates before mor- bid secretions have been discharged, nor to allow the bowels to become constipated, otherwise a chronic state of the disease or dysentery may supervene. 30. (b) The chronic form of this variety usually arises either from a neglected or injudi- ciously treated acute stage, or as a sequela of dysentery ; it is also very common in children ; and often occasions, as well as attends, obstructed mesenteric glands. There is no ailment, par- ticularly when existing in children, that requires more discrimination than this. If, after an at- tentive enquiry into the history and previous treatment of the case, as well as into its existing state, we find the abdomen hot, the skin dry and harsh, the tongue red at its edges, or its papillae erect, and the pulse excited but not weak, local depletions are required, and should be followed by the tepid or warm bath, or by fomentations, dulcis 3 vj. ; Spirit. Lavandul. Comp. 3 j. M. Fiat Haus- tus quater die sumendus. The purging ceased; the motions became feculent, and of a healthier colour : the severe paroxysms o< pain, and the tenderne s complained of in the region of the duodenum, and ducts subsided ; and the catamenia became, after a few doses of the borax, copious and more natural. 530 DIARRHCEA —Treatment of Lienteric. and by moderate doses of the purgatives last magnesia, tragacanth, &c. The mistura crete, recommended. As soon as the stools are im- with tinct. camphorae comp. and mucilage ; the proved by these means, aromatics with opiates, decoction of logwood, with laudanum; the hy- or absorbents, or both (F 623. 633.*, may be prescribed; and warm clothing, with light farina- ceous food, allowed. If these means be insufti- drarg. cum creta, with pulv. ipecacuanhas comp., and either an aromatic or an absorbent ; the nitro-muriatic acid, with tinct. opii, in tonic cient, a blister, or rubefacients, &c. applied over infusions ; a decoction of cusparia, with nitric the abdomen, and the hvdrargyrum cum creta, acid and laudanum ; the infusion of catechu, with the pulvis ipecacuanhas comp. (F. 653.), with aromatics ; sulphur, with carbonate or sub- and small doses of rhubarb, given night and borate of soda and opium; camphor, with nitrate morning, or even oftener, will be of much ser- of potash, or chlorate of soda, und tragacanth ; vice. Thave frequently prescribed, with the great- j the chlorates, with demulcents or emollients; the est benefit, in chronic cases both of this and ! nitrate of silver, with tonic extracts, &c. ; the the preceding variety, the sub-borate of soda, with sulphates of copper, or of iron, or of zinc, or honey, and the compound powder of tragacanth the nitrate of bismuth, either alone or with opium and capsicum. lime-water; blisters and rubefacients; demulcent, 31. (c) Chronic mucous diarrhcea, with I emollient, and opiate clysters; tepid salt-water whitish, greyish, or mucilage-like stools, arising from the absence of bile, the imperfect absorp- tion of the chyle, and the morbid state of the mucous secretion, requires low diet, consistin bathing, followed by frictions with rubefacient liniments (F. 296. 305.), and tonic plasters, with flannel rollers round the abdomen; are the means which are most to be depended upon, in this un- entirely of farinaceous substances. At the same favourable state of the disease. Animal food time, the hydrarg. cum creta ought to be ex hihited twice or thrice daily, with the sub-car generally increases the disorder, and farinaceous articles of diet should be iu moderate quantity, bonate of soda or potash, and minute doses of. or taken after short intervals opium. A tonic or stomachic, powder or mix- ture should also be prescribed, with the warm bath, and frictions of the surface upon coming out of it. If these means fail, there is probably disease of the mesenteric glands,—the liquor potnssae may be given in beef-tea, the mild mer- curial continued every night, and the purgative draught already directed (§ 29.) also be tried. In some obstinate cases of this kind, I have 33. E. Diarrhoea with indigested Matters in the Stools.—The treatment in this variety should be directed principally with the intention of pro- moting the functions of the stomach and duo- denum. These may, particularly in children, and during the period of dentition, be disturbed by inflammatory irritation of the mucous surface, associated with increased action of the muscular coats (§ 12.); whenever, therefore, this con- resorted to the chlorates of the fixed alkalies or , dition is presumed, leeches should be applied of lime, conjoined with the compound tragacanth over the epigastric region, and be followed by a powder, and aromatics (F. 283.), with great | sinapism, or a blister, with tissue paper interposed benefit. It will generally be necessary in this between it and the skin, or by a rubefacient cata- state of the disease to rouse the digestive and assimilative functions by tonics, and the action of the liver by mild mercurials ; and to combine these remedies with antacids, or with demulcent: plasm or liniment. As the biliary functions are usually torpid or otherwise morbid in this variety, and the mesenteric glands often diseased, hy- drarg. cum creta, with sub-carbonate of potass, and aromatics, or with balsams or the terebinthi- ought to be given at bed-time. The digestive nates. The infusions of calumba, or cascarilla, | functions will be most permanently promoted by or cinchona, or cusparia, with carbonate of am- j the infusion of cinchona, or catechu, or casca- monia, and confectio aromatica, may be first employed ; and afterwards the balsams, or vegetable and mineral astringents. In more obstinate cases, the warm salt-water bath, or a tonic, stimulating, or gently rubefacient plaster to the abdomen or loins, or both, may be prescribed, and the trunk surrounded by a flannel roller ; a light farinaceous diet being allowed. The treat- ment now described is requisite equally in child- ren as in adults. This form of chronic diarrhcea is most common in the former ; and when ii is rilla, or calumba, or of cusparia and rhubarb, with liquor potassae, or sub-carbonate of ammo- nia, and small doses of opium (see F. 413". 623. 788. S70.); or by chalybeate preparations, par- ticularly the ammonia-tartrite of iron, with lau- danum, or extract of syrup of poppy, or tincture or extract of hop. The use of recent ox-gall, as recommended by Horn (Archiv. Mar. 1810. p. 335.), or F. 481., is appropriate in this and the two preceding varieties, and will be very beneficial when it can be exhibited. In addition connected with dentition, requires constant at- j to these, and other internal and external remedies tention to the state of the gums. already noticed, the tepid or salt-water bath or 32. D. Diarrhoea from Ulceration requires < semicupium, will also be productive of much ad- very nearly the same treatment that was recom- I vantage, particularly when followed by frictions mended for chronic mucous diarrhoea (§ 31.), of the abdomen or spine with stimulating embro- of which it is generally only a modification or j cations or liniments. consequence. When the evacuations in this I 34. iii.—(a) Diarrhoea in the Puerperal Slate variety are fluid, or muddy and foetid, and with-| (§ 14.), when it arises from accumulations of out tenesmus, the disease is most probably seat- faecal matters and morbid secretions, requires ed in the small intestines; and when arrested by the use of gentle laxatives and mild purgatives, opiates and astringents, uneasiness at the stom- assisted by emollient and aperient clysters, with ach, with nausea and sickness, are usually pro- j strictly regulated diet. After the offending' mat- duced. Besides the means noticed in the pieced-j ters are evacuated, opiates should be exhibited. ing paragraph, the terebinthinates and balsams | When bilious vomiting accompanies diarrhcea, may be given, with small doses of rhubarb,' or when the stools are bilious, demulcents, di- DIARRHCEA — Treatment op, in Children. 531 luents, and mild laxatives are requisite, until the | morbid secretions are evacuated ; but if spasms with much irritability of stomach be present, ophtes must be immediately exhibited, with magnesia, and nitrate of potash, which will gener- ally remain upon the stomach ; but if tliese be vomited, small opiate clysters or suppositories should be administered. As long, however, as the stools continue offensive, or otherwise mor- bid, mild laxatives, and an occasional dose of calomel or blue pill, should be prescribed. In other respects the treatment is to be conducted i according to the principles already sketched. — ' (6) When, in addition to the accumulation of morbid secretions, slight or chronic inflammation of the mucous surface of the bowels, with serous dark-coloured and offensive evacuations super- \ vene, an emetic of ipecacuanha, if given suffi- j ciently early, will be of service. After its oper- ] ation, or independently of it, three or four grains of calomel, or five or six of hydrarg. cum creta, , with a little magnesia, may be exhibited, and in a few hours afterwards either a dose of fresh castor j oil, or any other mild purgative. If griping be ! present, an emollient and opiate enema should be administered. If the lochia be suppressed, the sub-borate of soda, in doses of from ten grains to a scruple, may be given three or four times daily, in emollient decoctions or infusions (F. 209. 630. 867.), or the liquor ammonia; ace- tatis, with spirit, amnion, arotnat. and camphor mixture, may be prescribed ; mild purgatives or laxatives being repeated occasionally, until the tongue becomes clean and the stools natural. If the disease be not relieved by these means, and if pain be felt in any part of the abdomen upon well-directed pressure, or if a sense of heat or the symptoms of serious diarrhcea be present, general or local bleeding, with the rest of the treatment recommended in that variety (§ 28.), should be put in practice. Having removed morbid matters, or inflammatory irritation, where either or both exist, demulcents, absorbents,gentle restoratives, and tonic or astringent infusions, with mild diet, may be prescribed. 35. iv. In Infants and Children, diarrhcea assumes the bilious, serous, mucous, and lienteric characters: the former two more frequently before weaning, and in an acute form, or at a more ad- vanced age in connection with irritation in the brain; the latter more usually after weaning, and in the chronic states (§ 16.).—(a) In slight diar- rhcea, with fluid feculent motions, small doses of rhubarb with magnesia (F. 623. 633.), a grain or two of hydrarg. cum creta at night, and the tepid bath, are all that is required; care being taken that the bowels shall not become costive. If the dis- order be occasioned by improper ingesta, or over- feeding, or if it be attended by fever, an ipeca- cuanha emetic should precede the above means, which ought to be followed by a dose of castor oil; and a grain or two of calomel ought to be given at bed-time, as advised by Dr. Clarke (Mem. of Irish Acad. vol. vi.). When the stools are slimy or serous, and ejected forcibly, | with tenderness on pressure, leeches and foment-, ations should be applied to the abdomen, and I small anodyne and emollient clysters thrown up. If the evacuations emit a sour smell, and if they be greenish, or curdled, or frothy, cretaceous substances and magnesia^ or ammonia, with aro- matics, and occasionally with opium or syrup of poppies, ought to be exhibited : after the more urgent irritation is subdued, mild purgatives will still be required, and should be repeated, when- ever the evacuations are morbid. Great caution is necessary in exhibiting opiates to infants, either by the mouth, or in clysters, and they ought not to be given when the symptoms indicate the reten- tion of morbid matters in the bowels. In order to evacuate these matters, the following may be pre- scribed :— No. 176. R Spirit. Ammon. Aroinat. "jss.; Olei Ri- cini Syrup. Rosa>, et Mannw Opt., aa s ss- i Aquae Pimen- la: et Aq. loin, aa ' j. Fiat EmuUio, de qua, sumatur Goch. unum minimum vel mediocre, pro re nata. Vel, .No. 177. It Potass* Tartar. 5 ij. : Infus. Sen ia? Comp. et Aq. Ka-niculi Dul aa 5J-i Syrup. Senna: ^ss.; Olei Anisi TTJ vj. Fiat Mist., cujus capiat Coch. unum me- diocre vel amplum pro dosi. No. 178. H Hydrarg. c:.m Creta gr. xij.; Sodae Pub-car- bon, exsic. 3,s-' -Camphorae rass gr. iij.; Pulv. Ipecacu- anhs, Pulv. Opii, aa gr. j. Pulv. Cinnamom. gr. xviii. ; Sacchiii Albi 3j- S Olei Anisi TTJ iv. Tere probe siiuul, et divide in Cartulas xij., quarum omni nocte, vel mane nocteque, capiatur una. 36. When the diarrhcea proceeds from wean- ing, either prematurely or at the proper time, the treatment now advised, or that recommend- ed for the mucous variety (§ 30, 31.), should be employed. Dr. Cheyne directs small and repeated doses of calomel ; but, unless morbid matters are accumulated in the prima via, — when it should be given in a full dose, and be followed either by castor oil, or the mild purga- tives alreody prescribed, — the hydrarg. cum creta, with magnesia and Dover's powder, or F. 923., is preferable. When the stools are slimy or bloody, or squirted out forcibly, leeches should be applied to the abdomen, and these medi- cines be also given in small but frequent doses ; fomentations, demulcent clysters containing olive and castor oil, the tepid bath, and warm clothing, being also prescribed. If it assume the acute cha- racter, or at the commencement of the attack, the treatment prescribed in the article on the Chole- ric Fever of Infants (§ 11. 15.), of which it is merely a modification, is in every respect appropriate. When it passes into the chronic form, the means recommended with reference to chronic mucous diarrhoea, or the ammonia-tartrite of iron, with confectio aromatica and compound tragacanth powder, should be employed ; the hydrarg. cum creta and Dover's powder being exhibited every night. The abdomen or spine ought also to be rubbed night and morning with either of the liniments (F. 296. 300. 311.), upon coming out of the tepid or warm bath, and be rolled in flannel. When the patient's strength is not much reduced, and if there be fever, and offensive evacuations, much benefit will result from a dose of calomel, with a grain of James's powder, at bed-time, and from one to two drachms of castor oil, with half a drachm of the spirits of turpentine, taken on the surface of fennel water the following morning. Clysters of beef-tea, or of strained mutton or veal broth, well salted, may also be thrown up ; and the chlorates of the alkalies or of lime, or lime-water; the sulphate of iron in small doses, with the sulphate of potash ; the liquor potassae, or the sub-carbon, of ammonia, with infusion of cin- chona, or of catechu, or F. 183. 536. 363. &c, may be prescribed. With a light nutritious (chiefly farinaceous) diet, a suflicient quan- 532 DIARRHCEA —Treatment of its Complications. tity of salt should be taken ; and if the vital I powers be much depressed, warm spiced port J wine negus may be allowed in small quantities. > In the variety attended by copious, pale, albu- minous urine, &c. (§ 17.), strong jellies and soups, animal food, fresh eggs very lightly boiled, the chlorates, with small doses of rhu- barb, vegetable and mineral tonics and astrin- gents, the preparations of iron, warm salt-water baths, and frictions with stimulating liniments, are the most beneficial. If the bowels become constipated, the mildest laxatives should be prescribed. If the urine be much diminished in the more common form of the disease after weaning, the spirit, aetheris nitrici ought to be given ; and if drowsiness or coma supervene, blisters may be applied behind the ears. These last symptoms are more frequently the conse- quence of exhaustion than of effusion, when they occur late in the disease : or if effusion j take place, it is the result rather of the physical state of the brain, a serous fluid poured out from the vessels filling the vacuum that would other- wise have been left by the anaemic and atrophied.■ encephalon, and requires tonic and restorative remedies. In such cases, more advantage will accrue from measures calculated to support the vital powers, to allay irritation in the prima via, and to determine the circulation to the external surface, than from those which depress the ener- gies of life, although they may act beneficially in other respects. It is necessary to watch care- fully the state of the gums throughout this serious and obstinate form of diarrhcea, and to lance them whenever they indicate the propriety of the operation.— (d) If the diarrhoea, either in infants or older children, be symptomatic of cerebral congestion, irritation, or inflammation \ (§ 35.), leeches behind the ears, calomel with James's powder, the semicupium, cold affusions on, and cold applications to, the head, with cool- ing diaphoretics, diuretics, and external deriva- tives, are the chief remedies. 37. v. Diarrhoea in the Dark Races requires a much more general and liberal use of aromatics, absorbents, and warm astringents, than are admis- sible in the white variety of our species. In them, capsicum and the other hot spices, with cretaceous powders and mixtures, the preparations of ca- techu, of kino, of iron, &c, are almost indispen- sable. When symptoms of retained faecal matters are present, purgatives are requisite, but they should be of a warm and tonic kind, or be com- bined with substances of this description. Al- though diarrhoea is only occasionally complicated ■ with intestinal worms in Europeans, and then chiefly in children, or in the inhabitants of low, moist, warm, imperfectly ventilated and unhealthy places, it is very often thus associated in the dark races, and at every age. This circumstance, therefore, should suggest the employment of an- thelmintics, especially those which are tonic and astringent, as the decoction of the pomegranate root, or the pink-root, or the male fern, in pre- ! ference to other medicines, particularly when \ these parasites are suspected to be present. In this class of subjects, whether diarrhcea be thus | associated, or simple, a suflicient quantity of salt with aromatics should be allowed, and the pa- tient's strength be kept up by suitable nourish- ment, and by vegetable and mineral tonics. 38. vi. The Associations of diarrhoea (§ 19.) require the greatest discrimination.— (a) When it accompanies the invasion offevers, it generally proceeds from the irritation of retained excretions and acrid secretions in the prima via. 'lhese should be evacuated by an ipecacuanha emetic, and by diluents and demulcents, followed by a full dose of calomel, and this latter by a mild purgative and oleaginous enema. If signs of vital depression exist, warm diaphoretics with ammonia, and occasional doses of rhubarb with magnesia, and the warm bath, should be after- wards prescribed ; but if febrile excitement ac- company the diarrhoea, saline refrigerants, and the rest of the treatment recommended in the serous variety, will be necessary. (See Fevers.) — (b) When the disorder accompanies gout, or occurs in the gouty habit, it should not be checked. Mild purgatives may be first pre- scribed in conjunction with preparations of am- monia, or one of the fixed alkalies ; and when morbid secretions and faecal matters are eva- cuated, full doses of magnesia, or of potash or soda with the spirit, colchici ammoniatus, and afterwards mild tonics, will generally restore the digestive functions.—(c) When diarrhcea is com- plicated with bronchitis (§ 19.), as often occurs during dentition, local depletions, lancing the gums, and calomel or hydrarg. cum creta, fol- lowed by a mild purgative, and these by diapho- retics, demulcents, emollients, the tepid or warm bath or semicupium, and attention to diet and warm clothing, are the means to be chiefly de- pended upon. In many of such cases, ipecacuanha emetics, and in others, camphorated refrigerants, will be productive of great benefit : the former when the bronchi are much loaded, and the stools are mucous and offensive; the latter when there is much heat of skin, and serous or watery evacuations. — (d) Diarrhcea complicated with scarlatina, measles, or small-pox, must be treated with strict reference to the state of vital power, the appearance of the eruption, and the cha- racter of the evacuations. These important complications are particularly noticed in the articles on these diseases ; but I may here re- mark, that a sudden arrest of the evacuations may be followed by effusion within the head, and coma, whilst their unrestrained continuance may occasion exhaustion, or fatal disorganization of the intestinal mucous coat. The treatment should therefore be directed, in such cases, with the intentions of diminishing inflammatory action in this part by moderate local depletions, of equalising the circulation and secretions by ex- ternal derivatives and relaxants, and by diapho- retics and diuretics, and of supporting the powers of life, whenever they become depressed, by diffusible and permanent stimulants. I may state as the result of experience, that, when this complication follows an imperfect developement, or retrocession, of the cutaneous eruption, even moderate depletions are not well borne, unless they be accompanied by warm diaphoretics and diffusible stimulants ; and that, of the latter me- dicines (which are very generally appropriate), full doses of ammonia, or of camphor, or of both, in some instances combined with nitrate of potash, in others with alkaline carbonates or magnesia, in most with demulcents and emollient diluents, in several with laxatives, and in many DIARRHCEA — Notices of Remedies recommended by Authors. 533 with aromatics, or tonics and antiseptics, have proved the most beneficial.—(e)When a diarrhcea that is not critical accompanies or follows remit- tent,continued,or adynamic fevers,the evacuations being watery, muddy, dark-coloured, or otherwise morbid, the hydrarg. cum creta, with ipecacuanha, camphor, and cretaceous substances; or the tere- binthinates and the balsams, with vegetable or mineral astringents; also tonics and antiseptics, the nitric and muriatic acids, or both; or rhu- barb with magnesia; the chlorates with demul- cents; external derivatives with warm rubefacient and stimulating liniments, &c, are the chief remedies, and the most likely to prevent the extensive sloughy ulcerations that sometimes at- tend the diarrhcea that supervenes either during, or subsequently to, these diseases. 39. Colliquative diarrhaa is sometimes not easily controlled; and even when most readily repressed, the constitutional disturbance may be thereby increased. It is most benefited by small doses of the sulphates of copper and of zinc (F. 577. 587.), by the mineral astringents generally, and by the cretaceous and demulcent preparations, combined with camphor, aromatics, and opiates, or with tonic and astringent infu- sions and decoctions, which, at the same time that they alleviate the symptoms, also support the vital energies. But the adoption and com- bination of these, or the choice of other remedies already or about to be noticed, should depend mainly upon the nature of the primary disease, of which the diarrhcea is, in this state, merely an advanced symptom. 40. Cautions, fyc.—The critical manifestation of diarrhcea should never be interfered with, un- less it either proceed so far as to depress the vital energies, or be attended by signs of inflammatory disease of the mucous surface and follicles, in which case the treatment recommended for the varieties indicative of such disease and its con- sequences should be prescribed. When diar- rhoea occurs in gouty or asthmatic persons, or in those of a plethoric habit of body, or who have a tendency to, or have suffered from, cerebral affections, or hepatic disorders ; or in the leuco- phlegmafic and hydropic diathesis ; it ought to be treated with much caution ; and should be only at first moderated, if very severe, by mild purga- tives or laxatives ; by depletions, diaphoretics, and diuretics ; by a regulated diet; and by warm clothing, according to the circumstances of the case, because the sudden arrest of the evacuations by opiates and astringents may be attended by some risk. 41. vii. Notices of particular Remedies recommended by Authors, &c.—A. Bleed- ing has been advised by Cotu g n u s (De Veneesect. in Diarrh. Rom. 1604.); by Horstius (Opp. iii. p.68.);by ZacutusLusitanus (Med. Pr.Hist. 1. ii. p. 734.); in the bilious variety, and by Syd- enham. It is obviously requisite in the inflam- matory states of the disease, whether acute or chronic, and preferably by leeches applied to the abdomen, to the sacrum, or to the verge of the anus, particularly when tenesmus is present. 42. B. Refrigerants are always beneficial in the serous and mucous varieties, and when the com- plaint is attended by increased heat or excited circulation, and erect papillae of the tongue ; and they may be combined with demulcents and opiates 44 (F. 36. 821. 838. 886.) according to the circum- stances of the case. Of this class of medicines the nitrate of potash or of soda, camphor (F. 431.), the muriate of ammonia (F. 352. 431.), borax (F. 209. 630. 867.), variously combined, and the tepid bath, are the most appropriate. Re c a mie r (Annuaire M d. Chirurg. vol. i. p. 113.) recom- mends nitre with the oxyde of bismuth, and opiated aromatics. Hufeland prefers the muriate ofammonia(STARCK,^rcAi». b. i. st. 3. p. 93.) in the inflammatory states, and when it accompanies fevers ; and Zadig combines it with mucilaginous substances (Journ. der Erfind. st. xxi. p. 57.). 43. C. Laxatives and mild purgatives have al- ready been sufficiently noticed. Those of an irri- tating nature are not unfrequent causes of the complaint, and ought never to be prescribed. Even castor, olive, or almond oil, if they be iu the least acrid or rancid, will be productive of much mischief. I have seen enterilis supervene on diarrhcea from this cause. In the chronic states of the disease, sulphur, with cream of tartar and | sub-borate of soda, in the form of electuary i (F. 790.), and conjoined with aromatics, is often I the best laxative that can be employed. It has been preferred by Lance (Miscell. Verit. p. 29.), and it possesses the advantage of relaxing the skin. 44. D. Diaphoretics are of much benefit in all j the febrile states of the disorder, particularly the serous variety, and are advantageously com- bined with refrigerants. They have been adopted by Sydenham, Diemerbroeck (Observat. et ■ Curar.No.64.),L,ENTiN (Beytruge, b. iv. p. 332.), Osiander (Denkwvrdigkeiten, b. ii. p. 179.), &c. The chief of this class are James's powder, ipecacuanha, camphor, carbonate and acetate of ammonia; spiritus aetheris nitrici (F. 394. 840.), &c. Ipecacuanha, particularly when associated with nitrate of potash, camphor, and opium, is one of the most certain and efficient remedies we can prescribe in all the acute forms of the disease ; and it is also a very useful adjuvant of other medicines (see F. 39. 495. 642. 744. 924.). It has been very generally used, and particularly by LinnjEijs (Amoen. Acad. Upsal. vol. viii. p. 246.), Fothergill (Med.Observat.and Inquir. vol. vi. art. 18.), Baldinger (N. Magazin. I b. xix. p. 404.),Stark, Loeffler (Beytr ge, b. i.), and Broussais (Loc. cit. in Bibli.), either ■' in the combinations now noticed, or in those con- \ stituting the old and new Dover's powder. It may also be given with the nitrate of soda, and opium; or with the tormentil, as formerly directed by me (Lond. Med. Repos. vol. xviii. p. 329.). 45. E. Demulcents and emollients are of ser- vice in all the varieties of diarrhcea ; those of an oleaginous kind, in the form of an emulsion, when a laxative is required, as the castor, olive, or almond oil, with ammonia, or the fixed al- kalies, &c.; and those of a mucilaginous descrip- tion, when a constipating effect is desired, as the compound powder of tragacanth (F. 389.), or mucilage of acacia, and decoction of Iceland moss (Lind. Herber, »'n Horn, Archiv. Nov. 1810, p. 289.); and they may be combined with refrigerants, or opiates, aromatics, absorbents, or astringents, — also with sedatives, as the hydro- cyanic acid, the preparations of morphine, or of hyoscyamus, or of hop, or those of ipecacuanha, according to circumstances. (Seethe Emulsions, in the Appendix.) They are often of great ser- 534 DIARRHCEA —Notices of Remedies recommended by Authors. vice when administered in the form of small clysters, conjoined with opium, as advised by Sy- denham (Opp. p. 87.),Hildfnbrand (Hufe- land, Journ. der Pr. Heilk. b. xiii. st. 1. p. 148.), and Hufeland (in Ibid. b. xxvi. st. 3. p. 155.). 46. F. Absorbents are especially indicated when the complaint is connected with acidity in the prima via ; and the cretaceous, magnesian, and ammoniacal substances, combined with opiates, aromatics and astringents (F. 37. 347. 354. 384. 442. 648.), are the most serviceable when re- laxation of the mucous surface and debility exists; and the sub-carbonates of the fixed alkalies, asso- ciated with refrigerants (F. 838.), when inflam- matory action is present in this surface. 47. G. Aromatics (F. 348. 363.) are particu- larly requisite in asthenic cases, and if the patient has been in the habit of using hot condiments and spices with his meals ; or when the diarrhcea arises from unwholsome water, from stale animal food, and from endemic causes ; in which cir- cumstances, charcoal, in large doses, as recom- mended by Dr. Jackson, and some American physicians, may also be given. Aromatics are best combined with absorbents and vegetable tonics or astringents. 48. H. Tonics, particularly calumba (F. 51. 869.), cascarilla (F. 870.), and cinchona (F. 380, 381.), are often requisite, especially in con- junction with the alkaline and other absorbents, and with aromatics, opiates, &c.; and in the idiopathic, the asthenic, and chronic states of the disease. In such cases, and thus combined, calumba has been recommended by Percival (Essays, vol. ii. p. 3.), Stark (Klin und Anat. Bemerk. p. 7.), Thomann (Annalen. ad 1800, &c), Frank (Acta Inst. Clin. Viln. Ann. ii. p. 79.), Fischer (in Hufeland, Journ. d. Pr. Heilk. b. xvi. st. i. p. 123.), and Lichtenstein [Ibid. b. xix. st. i. p. 180.); quassia, by Lett- som (Mem. of Med. Soc. of Lond. vol. i. p. .); cascarilla, by Bang (Act. Reg. Soc. Med. Haun. vol. i. p. 241.) and others ; the willoio bark (F. 414.), by White (On the broad-leaved Willow Bark. Bath, 1798.); and the cinchona with opium, by Pico.ue (Journ de Med. t. xlii. p. 433.) and Schmidt (Horn, Archiv. b. v. p. 236.), chiefly when the complaint assumes a periodic form, or is connected with remittents or inter- mittents. Nux vomica and styrchnine have also been prescribed in atonic diarrhoea: the extract of the former, by Theussink, Oswald (Archiv. der Pr. Heilk. f. Schlesien, b. ii. st. 4. art. i.), Horn (Archiv. Nov. 1810, p. 258.), and Rummel ; the latter, by Recamier and Graves (see Bibl.) who gave the twelfth part of a grain of it twice or thrice a day, with complete success, in an obstinate case of white mucous diarrhcea. Dr. Rummel considers it particularly efficient in removing this very ob- stinate form of the complaint, when seated in the lower bowels. 49. /. Astringents are requisite in similar states of combination as tonics, and in the same forms of the disease. They are not admissible in the bilious variety, or where faecal collections or acrid matters are retained, or in the inflammatory states of the complaint, until after depletions, refrigerants, and diaphoretics have been em- ployed ; but they are seldom of use whilst the temperature of the surfaee is increased, and the pulse accelerated, although M. Bally s expert- ments indicate the contrary.—a. Of the vegetable substances belonging to this class, the most ser- viceable are catechu, kino, the pomegranate bark or root, the cusparia or angustura bark, logwood, &c, and some mineral substances. The prepa- rations of catechu with those of chalk and opiate confection, or F. 30. 183. 788., are very gene- rally employed, as well as those of kino (F. 34, 536.). Some doubts exist as to whether catechu or kino is most serviceable. Dr. Pembertob preferred the latter ; and M. Bally (Gazette de Sant', &c. 1829, and Med. Guz. vol. v. p. 700.) found, from an extensive trial of it, that it gene- rally arrested chronic diarrhcea, without fever, in four or five days, when taken to the extent of from twelve to twenty grains daily ; and that, even in diarrhcea with fever, and tenderness of the abdomen on pressure, it was equally suc- cessful. The bark of the root of the pomegranate, as well as its flowers, and the exterior of the fruit, have been long employed in diarrhcea in Eastern countries. They were much prescribed by Mead, Strandberg,and Cullen. Mead gave them in the form of decoction with cinna- mon and red roses. They are very beneficial when the diarrhcea is complicated with worms. The cusparia or angustura bark was much praised by Lettsom (Mem. of Med. Soc. of Lond. vol. vi. art. 15.) and Theussink ; and is an excellent medicine, either in substance, tincture, or infu- sion (see F. 201. 413.). The krameria, or rhatany root, first employed in diarrhoea by the I Spanish physicians, Dr. Ruiz (M^m. de I' Acad. ! Roy. de Madrid, 1796, p. 364.) and Dr. Hur- tado (Journ. de M'd. 8fc. t. xxxvii. p. 216.), has since been used with advantage iu this ' country (F. 734.). The simarouba bark was re- commended by Jussiec,Capet, Frize (Anna. len, i. p. 59.).and Werlhof (Observat. de Febr. sect. iii. § 6.), but chiefly in the diarrhcea at- tendant on fevers ; and the mahogany bark, by Hughes (Med. Facts and Observ. vol. vi. art j 10.). These may be prescribed in the form of [ infusion with the arnica, the root of which has been much used by Theussink in this complaint. The logwood is an excellent astringent, and, in the form of decoction, a suitable vehicle for other remedies. The bistort, the uva ursi (F. 217. 396.), and tormentil, are also of much ser- vice, particularly when associated with ipeca- cuanha. The root of comfrey, the comolida major, is recommended by Hufeland (Journ. der Pr. Heilk. 18L 9.); and the lythrum salicaria, by Blom, Bang (Op. cit.), De Haen (Rat. j Med. par. iii. par. 195., p. iv. p. 250.), and Herz (Briefe, st. i. art. i.). They are much employed in the north of Europe. 50. b. The mineral astringents are very bene- ficial in several of the forms of diarrhcea, par- ticularly the chronic. Lime in various forms,—in cretaceous powders and mixtures, chiefly as ab- sorbents ; and in the state of chlorate (F. 283.), or recent lime water, as powerful astringents,— are very serviceable, especially when associated with demulcents, mucilages and aromatics. I have used the chlorate of lime on many occasions with advantage ; and lime water, with boiled milk, or with the other medicines just referred to, is in ; very general use. Alum, also, variously com- bined, or in the form of Alum whey, has been DIARRHCEA — Notices of Remedies recommended by Authors. 535 praised by Adair (Edin. Med. Comment, vol. ix. p. 21.) and Harrison (New Lond. Med. Journ. vol. ii.). It may likewise be given with other astringents, or with aromatics and opiates. The superacetate of lead was prescribed by Dr. Archer (N. Y. Med. Repos. vol. iii. No. 3.), with opium ; but Horn (Archiv. b. vi. p. 144.) states that he found it of no use. I have seen benefit derived from it in the diarrhcea at- tending the advanced stages of phthisis. The sulphate of copper has been tried successfully by Dr. Elliotson, in doses of from half a grain to two grains, given twice or thrice a day, with opium ; and the ammoniated copper has been prescribed by Bianchi (Brera, Comment. Medici. Dec. i. vol. ii. art. 2.). The sulphate and oxide of zinc are also useful, especially when combined with rhubarb, or myrrh, or the balsams, or terebinthinates (F. 578. 587. 666. 875.). The nitrate of silver, triturated with a tonic or astrin- gent extract, and in small doses, has been em- ployed by me on various occasions with advan- tage, particularly in the mucous variety, and in very chronic cases. The mineral astringents are often the most efficacious in colliquative diar- rhoea. 51. K. Besides the above, there are other reme- dies which may be noticed. These are, the tussila- go (Percival, Essays, vol. ii. p. 224., and Fri- borg, in Todes Biblioth. b. i. p. 118.) ; large doses of almond oil, as an emollient and laxative (Vallisneri, Opp. iii. p. 278.); the infusion of the diosma crenata (F. 231. 396.); the plantain in demulcent broths; unripe medlars (Forestus, Opp. vol. iii. p. 47.) ; the root of the geum ur- banum (De Meza, in Acta Reg. Soc. Med. Haun. vok ii. No. 4. p. 28., and Ranoe, in Ibid. vol. iii. p. 369.); the Peruvian, Canadian, and other balsams (F. 369.); the briony (Arnaud, in Journ. de Med. t. lxxvi. p. 257.); the de- coction of elm-bark (Collingw-ood, in Edin. Med. Comment, vol. xvi. p. 58.) ; and camphor (Thoma.nn, Annalen ad 1800, p. 355.); which latter I have already recommended, from a fre- quent experience of its good effects when judi- ciously prescribed. Sarsaparilla will also be found useful in chronic states of the complaint, and may be associated with the decoctions of elm-bark or of Iceland moss, or with lime-water or liquor po- tassae; small doses of hydrarg. cum creta, with Do- ver's powder, being exhibited at bed-time. Bang advises salivation in obstinate cases; and in rare instances it may be advisable to resort to it. Dr. A. Stout (Phil. Med. Journ. May, 1823.) states that he cured a case of diarrhcea from suspended menstruation by the ergot of rye, given in doses of six grains three times a day. 52. L. The administration of most of the medi- cines noticed in the course of this article, in the form of clyster, will prove of much benefit, whenever signs of disorder in the course of the colon can be traced, or when the complaint has been preceded by dysentery. In these, Horn (Archiv. b. vi. p. 139.) advises the infusion of valerian to be administered -in this way. An infusion of ipecacuanha may likewise be thus prescribed. When the diarrhoea assumes a chronic form, warm or tepid salt-water bathing, or artificial irritations and eruptions induced on the abdomen, and kept up for some time, will be generally serviceable. When this practice can- not be adopted, either warm, tonic, and de- obstruent plasters should be placed on the abdomen or loins, or a flannel belt or roller be worn around the lower part of the trunk. I have found a large plaster consisting of equal propor- tions of the emplast. picis comp., the emplast. ammoniaci cum hydrargyro, and the emplast. galban.comp., extremely useful, particularly when the complaint has been connected with hepatic disease. These means, in the most severe and ob- stinate cases, will be much promoted by slow and frequent or constant travelling, or sea voyaging. 53. M. The diet should be strictly regulated, not only in the course of the disease, but also during convalescence, and after recovery. Whilst the complaint continues, especially in the acute form, the food ought to be farinaceous, very mild, and in small quantity. In the chronic states, also, this injunction should be followed in many cases; the lighter kinds only of animal food, in small quantity, being allowed when the patient's strength requires it. Malt liquors, acid wines, and acid or over-ripe fruit, or pastry, particularly its crust, ought to be entirely relinquished. Good old port wine, however, or old sherry, will frequently agree with the patient, and is often even requisite. In cases requiring astringents and tonics, not only may wine be allowed, but also a substantial, but light, diet of well-seasoned and simply dressed animal food. The diet, dur- ing convalescence and recovery, ought never to be continued on so restricted a scale as to lower the patient's vital energies, without making trial of the effects of that which is more nutritious. Bibliog and Refer. — Galen, Local Aff ct. vi. 2.— Aitius, Tetrab. i. serm. iv. c. 19., let. ii. ser. i. c. 90. &c.— Alex. Trallianus, 1. viii. sect. 7. —Poncet, Ergo Fluxibus Alvi Purgatio Venaesectione commodior. Pans, 1571. — Lonerus, De Fluxu Diar. et Lienteriae, Stc. Naumburgi Observ. Lips. 1589. — Bassalis. Non ergo fluenti Alvo Evacuantia Paris, 1617. — Rolfinck, Diss. Patholog. No. xv. Jen. 1637.—Leiehner, De Diar. quddam Epi- de nica. Erf 1676. 4to.—Pichonet, Ergo Alvi diuturno Fluori Vomitus. Paris, 1686. —Fernethuys, An Omni Alvi Fluxui Radix Brasiliensis ? Paris, 1706.—Fontaine, An Alvi Diut. Fluori Vomitas. Paris, 1733. — Baglivi Du Pr. Med. i. cap. 9. — Vesti, De Diarr. Lochiis Super veniente. Erf. i713. — Morgagni, De Caus. Morb. kc. epist. xxxi. et Ixv. cap. 5. — A. Bergen, De Diar. Puerpt- rarum. Fr. 1721. — Cockburne^ Cure of Looseness, ic. 8vo. Lond. 1721. — Pi'jo, De Morbis ex Serosa Colluvie, p. 68. 234. — Weiss, De Damnis e Diar. Suppressa oriun dis. Alt. 1742. — A. de Jussieu, Ergo Inveter. Alvi Fluxi bus Simarouba, 4to. Paris, 1730. — Juncker, De Diar. plurium Annorum. Hal. 1745. — Capet, An in Inveter, Alvi Fluxibus Simaruba? Par. 1758. — Sauvages, Class ix. order ii. gen. 13.—Bang, Act. Reg. Soc. Med. Haun. ioI. i. p. 100. 243; et Selecta Diarii Nosocom. Regi: Hafn. vol. i. p. 47., vol. ii. p. 233, et seq. — Zadig, in Ar chiv. der Pr. Heilk. fitr Schle-ien b. i. St. 1. Art. 8.— D. Monro, Med. Transac. &c. vol. ii. p. 325. — C. Smith, Med. Comoiunicat. kc. vol. ii. p. 210. — Cullen, Works, by Thomson, vol. i. p. 312. 485., vol. ii. p. 485. — Baillie, Med. Trans. &c. vol. v. p. 166. — Batemun, arts. Diar- rhoea and Lientery, in Rees's Cyclopaedia.—Dewar, On the Diar. and Dys. of the Brit. Army in Egypt, 8vo. Lond. 1803. — Pemberton, On Disease's of the Abdom. Viscera 8vo. p. 148. — Bonte, in Journ. de Med. t. xxx. p. 27. 112. — Fischer, Vom Alter, p. 201. et in Hufeland's Journ. der Pract. Heilk. b. xvi St. 1. p. 107. — Broussais, Hist, des Phlegmasies Chroniques, kc vol ii. cap. 3.— Good, Studv of Med. vol. i. p. 270.— Rummel, Der Fluxus Cceliacus, oiler die Milehruhr kc. — Hufeland, Journ. der Pr. Heilk. June, 1825. — Elliotson, Transac. of M d. Chi- rurg. Soc. vol. xiii. p. 451.—Bums. Princip. of Midwif. ana Diseases of Women and Children, 6th edit. 8vo, p. 775. — Graves, in Dub. Hesp. Reports, vol. iv. p 46. — Dewers, On the Phys. and Med. Trea ment of Children, 8vo. Lond. 1826, p. 414. — Recamier, Arch ves Gener. de Med. t. xviii. p. 101. — C. F. Tacheron, Rech rchej Anat.-Patholog. sur la Med. Pratique, &c. 8vo. Paris, 536 DIGESTIVE CANAL—its I'athology. 1823, t. ii. p. 419. — Gardien, Des Maladies des Enfans p. 199. — Andral, Clinique M. dicale, t. i. p. 424.—P. M. Latham, Account of Dis. prevalent at the General Pe- nitentiary, &c. 8vo. Lond. 1825. — IV. P. Dewees, On the Ph "s. and Med. Treatment of Children, 8vo. Lond. 1826, p. 398. —Abercrombie, on the Diseases of the Stom., Intestinal Canal and other Abdom. Viscera, 8vo. Edin. 1S28, p. 206.— Bright Medical Reports, kc. vol. i. p. 172. — C. H. Ro he, Diet, de Med. et Chir. Prat. 1. vi. p. 287. — Marley, On the Diseases of Children, 8vo. Lond. 183', p. 65. — Annesley and Author, Researches on the Diseases of India and Warm dim tes, imp. 4to. vol ii. p.339.__(The author, in support of his own originality in some particulars, pathological and therapeutical, refers to some extended observations on diarrhoea in the Lond. Med. Repositoi-y, for 0 tober, 1822. p. 346.) DIGESTIVE CANAL — its Lesions. — Svn. Digestive Tube, Alimentary Canal, Prima Via, Gastro-intestinal Canal or Tube. Canal Gastro-intestinal, Fr. Classif.—General Pathology; Mor- bid Structures. I. The several morbid changes to which the digestive canal below the diphragm is subject, will be noticed here, in a general and connected manner, its principal diseases being described in- dividually in separate articles. 1 he changes ex- perienced by that part of the tube which is placed above the diaphragm, are detailed in the articles Fauces, (Esophagus, and Pharynx. 2. Of certain appearances in the digestive tube, that cannot be imputed to disease of any part of it, but which have often been mistaken for disease. — The internal surface of the stomach or intes- tines of a living animal, whose circulation is not disturbed, is of a red tint, somewhat deeper than that of the mucous membrane of the cheek of a healthy person. During the period of digestion the tint is much deeper, evidently owing to in- creased flux of blood; and its secretions and exha- lations are much increased. The red tint of health, however, disappears after death; and the digestive surface generally becomes uniformly pale, or slightly rose-colored in places, at the period when post mortem examinations are usually perform- ed. There are, however, certain circumstances which modify its appearances upon dissection, totally independent of disease of any part of the digestive canal. Some of these circumstances have operated shortly before death; others during the last moments only; and several either soon, or a considerable time, after the extinction of life. 3. (a) the causes which operate before death, are, 1st. The performance of the digestive pro- cesses, the increased redness of the villous surface attending them generally continuing after the cessation of life. 2d. The free return of the venous blood from the gastro-intestinal tube, to the right cavities of the heart, causing, in the first degree, simple congestion of the venous trunks ; in a higher degree, along or continuous with this congestion, an injection of the small vessels in streaks, stripes, patches, or points, with opacity of the injected parts; and, in the highest degree, a partial effusion of blood into the sub- mucous cellular tissue, forming ecchymoses, or into the cavity of the part, colouring red the matters contained therein. It is evident, not only that the disease of remote or related organs will thus affect the color and state of injection of the vessels of the digestive tube, according as it may impede or facilitate the return of blood from them, but that the kind, the mode, and phenomena of dissolution will have the same effect. Thus, death by asphyxia generally pre- sents a congested and deep-coloured tint of the digestive mucous surface. These facts, which seem to have been not unknown to Morgagni, to have been proved by experiment by Boer- haave, to have been observed in the cases of strangulation examined by Dr. Yelloly, and to have been demonstrated in cases of asphyxia, and by experiment, by the French pathologists, especially Billard, Andral, &c, are most im- portant, and evidently indicate that disease has been incorrectly imputed to the digestive canal, when the appearances whence the inferences were drawn, arose either from lesions of other organs, or from the mode in which death was produced. 4. (b) The causes of redness and injection of the digestive mucous surface operating after death, are 1st. The gravitation of the blood ; and, 2d. Its transudation through the parietes of the vessels. The first of these begins to act im- mediately after death, and whilst the blood is still fluid, as shown by the researches and ex- periments of MM. Trousseau and Rigot. The injection and redness of the intestinal parietes produced by gravitation, or injection from hypo- stasis, generally acquires its highest degree at the end of some hours from the extinction of life, and ceases to increase as soon as the fallen tem- perature of the internal parts allows the blood to coagulate. Hence, the longer the blood con- tinues fluid, and the more abundant it is in the vessels of the digestive canal, the more marked will be the injection of depending parts from hypostasis. The second of these post mortem causes of redness takes place at a remoter period— usually after twenty-four hours in summer, and after thirty-six or forty hours in winter'; but the period varies with the nature of the disease, and the state of the blood at the time of dissolution. This change commences first with red spots in the course of the vessels, isolated, grouped together, or running into one another, giving rise to coloured streaks, and evidently proceeds from the exudation of the blood through the vessels containing it. At a later period, the redness is not limited to the course and situation of vessels ; but the whole surface becomes more and more uniformly tinged, until it is equally red, approaching the appearance existing in the internal surface of the blood-ves- sels under similar circumstances. The following is a summary of the causes modifying the appear- ance of the gastro-intestinal canal; and which,in some respects, and with some additions, is the same as given by M. Andral. 5. The digestive mucous membrane is seldom of the same color in the healthy state. It may be—(a) perfectly white or whitish, although this state does not imply that functional disorder did not exist during life.—(6.) It may present various tints or degrees of colour, without ceasing to he sound, depending, 1. on the performance of the digestive processes, shortly before or at the time of death; 2. on the congestion to which internal vascular parts are liable at the last agony or moments of life; 3. on mechanical obstacles to the return of blood in the veins existing a longer or shorter period before dissolution; 4. on the gravitation of the blood to depending parts; 5. on the exudation of blood through the parietes of the vessels ; 6. on the exudation of this fluid DIGESTIVE CANAL —Functional Disorders of. 537 through the capsulae of the spleen ; 7. on the gases existing in the canal at the time of death ; 8. on the developement of other gases at a remo- ter period, when putrefaction commences; 9. on the combination of the colouring matter of the bile present in the digestive tube, with parts of its mucous surface; and, 10. on the medicinal or other ingesta, which may change its colour so as to resemble the morbid state. Some of the colours produced by these causes cannot be con- founded with that resulting from inflammation ; others very nearly resemble it, especially those occasioned by the 1. 2. and 4. and certain vari- eties of 3. and 5. Those states of the digestive surface that most nearly resemble inflammation, may in respect of it be denominated passive. M. Billard has given the following diagnosis be- tween passive and active or inflammatory red- ness of the villous or digestive mucous coat. — Infl immatory. Passive. a. With or without mani- a. The same. fest thickening of the membrane. b. Indifferently in a de- pending or elevated part. c. Without general injec- tion of the abdominal ves- sels, and without any obstacle to the course of the blood; sometimes con- sisting in only a slight lo- cal injection. d. With considerab'e ten- derness of the sub mucous tissue, and a capability of raising the mucous coat in large patches. e. With thickening and abundance of the intes- tinal mucus ; and some- times with sanguineous exhalation. 0. Almost always in a de- pending part. c. With general injection of the abdominal vessels, and with an obstacle to the course of Ihe blood ; rarely being an isolated local injection, but fre- quently occupying a fold of the intestine, or the whole intestine. d. A power of raising the mucous membrane in shreds only, which is the case in health. e. Without abundance or thickening of the intes- tinal mucus; but some- times with sanguineous exudation. 6. This diagnosis refers merely to the differ- ences between redness from inflammatory irrita- tion and redness from passive congestion. The various results of inflammation of the mucous membrane are entirely left out of the question. This tissue seldom experiences any change in density within the period which usually elapses between death and the examination. Therefore, softening can very seldom be justly considered a post mortem change. In respect, however, of the stomach, the case has been supposed to be otherwise, and upon good grounds. The obser- vations of J. Hunter and Allan Burns on the human subject; of Carlisle, Cooper, and Wilson Philip, on rabbits; of Adams, Bre- tonneau, and Trousseau, on dogs; and of Spallanzani on fishes; show that the solvent action of the juices of the stomach may be exer- ted upon itself, within twenty-four hours from death, so as not only to soften its villous coat, but to dissolve both it and the coats exterior to it, until the organ is perforated or destroyed in one or more places. The possibility of this occur- rence is shown by the experiments of Stevens, Lovell, and others, demonstrating the solvent power of these juices; and that it actually takes place, is established by the experiments of Drs. Camerer and Carswell, as well as by the sound health of the subjects of it at the time of death, and the absence of inflammatory appear- ances around the destroyed part, or in the peri- toneal coat. The healthy state of the other tissues composing the parietes of the digestive canal, and the natural capacity and position of its different parts, require no remark. 7. I. Functional Disorders.—The dispo- sition, which has prevailed for many years, and which is still so manifest in medical literature and practice, to impute every morbid condition to inflammatory action, and changes of structure, has been displayed more in this branch of pathol- ogy than in any other. Since the appearance of the writings of Marcus, and especially since the promulgation of the doctrine of Broussais, all the states of disorder referrible, directly or sym- pathetically, to the digestive organs, have been considered by many to arise from inflammatory irritation and action, or their consequences, in various grades or states of activity ; and even those who have not adopted the views of this very zealous writer, have too generally over- looked the primary and controlling influence of the vital endowment in the origin and removal, not only of the diseases of the alimentary canal, but of its related viscera, and, indeed, of those of all other organs. The pathologist who observes closely the action of the numerous agents which either merely change the conditions of life, as manifested in the sensitive and contractile sys- tems, or which produce alteratiohs of structure cognisable by the senses, and who notes the man- ner in which primary impressions affect related and even remote parts, must have often remark- ed, that some connection subsists between the nature of the agent, the particular system acted upon, and the effect produced; that the more ob- vious and palpable lesions are generally remote and often only contingent results; and that alterations apparently identical are often associated with, even when they are not the consequences of, very different states of sensibility and contractility, as well as of the other manifestations of vital power. It is necessary to our enquiries into the morbid states of a part, which, with reference to the formative and vegetative processes especially, is primarily and essentially vital, and which, from its intimate connection with the organic system of nerves, powerfully influences, whilst it is itself influenced by, the vital endowment or appro- priate influence of this system,—of a part espe- cially devoted to the preparation of the mate- rials for the reparation of the structures, and the support and perpetuation of life, — to view its changes of function and of structure accord- ingly, and with strict reference to the foregoing considerations. 8. i. Changes in the Desire, for Food and Drink. —If the alimentary canal be admitted to be, of all parts of the economy, that in which identity of lesion the least infers identity of symptoms, the same admission should be extended to the causes whence its lesions arise. Morbid states of hunger and thirst have, with other disorders of the digestive tube, been imputed either to in- flammatory irritation or action, or to organic changes. That they proceed, in many cases, from those lesions, must be admitted ; but that they uniformly or necessarily thus originate, can- not be maintained. — (a) Anorexia, or loss of appetite, although a very general attendant on all the organic changes observed in the stomach, is not uniformly present; for circumscribed lesions 538 DIGESTIVE CANAL —Functional Disorders of. have been sometimes found in this viscus, without this symptom having been observed. And, on the other hand, it often exists entirely uncon- nected with any change of texture. Both M. Louis and M. Andral have found, in persons who had long evinced the greatest aversion from every kind of food, the stomach perfectly sound. Anorexia appears frequently, independently of the evidence of post mortem research, to depend upon a change in the state of the nervous power, as shown by the influence of moral emotions, and mental and physical fatigue in producing it. Its occurrence as a symptom of all acute or serious diseases of related, as well as of remote organs, and of idiopathic and exanthematous fevers, is well known.—(b) The frequent connection of bulimia with irritation and organic diseases of the stomach, and even of the bowels, is admitted; but it is also dependent upon a temporary activity in the nu- tritive processes, as in convalescence from acute diseases ; and is then referrible to the condition of vital endowment, as manifested in the digestive and reparative functions.—(c) Pica, whilst it also often arises from chronic irritation of the stomach, is as frequently a symptom of disorder in the organic nervous system, and even of a morbid state of the blood, and it sometimes depends upon functional or organic change in some remote organ, / as the uterus or ovaria. (See Appetite, Mor- bid; and Chlorosis.) — (d) Thirst has also been imputed to irritation or inflammatory action; but, although it is certainly a symptom of this and other diseases of the stomach, and the rest of the digestive tube, it likewise arises from diminished exhalation and secretion in the pharynx and fauces; from the rapid discharge of the aqueous parts of the blood by the surfaces or kidneys; and from the superabundance of saline particles in the serum. . 9. ii. Disorders of the Functions of Chymi- faction, Chylifaction, and Facation.—That the numerous phenomena attendant upon indigestion may, and very often do, arise from various states of irritation or structural change in the digestive canal, particularly in its villous surface, is unques- tionable; and M. Broussais, although he has pushed the doctrine extravagantly far, has drawn attention to important and too frequently neglected facts. I must, however, contend that disorders of the digestive processes frequently cannot be referred, after the most patient investigation, to such sources ; but must be imputed to altered states of the vital or nervous power imparted to the viscera which perform these processes ; and that those pathological states generally are more or less intimately associated with debility and al- tered sensibility, or even wholly consist of these states, affecting either the alimentary canal and related organs, or the ceconomy throughout. (See Debility, § 15.) 10. A. In respect of chymifaction, or digestion in the stomach, the above positions cannot be dis- puted. For disorders of this function often depend upon causes which observation has proved inca- pable of directly influencing the organization, or of acting otherwise than upon the sensibility or the other manifestations of life displayed by this vis- cus, or even by organs affecting it sympathetically. The influence of moral emotions not only upon chymifaction, but also upon chylifaction and faecation, is well known. Moreover, the stomach has often presented after death no lesion to ac- count for the total deprivation of function long experienced during life ; and even when organic changes have been observed, they have not always been such as usually arise from inflammatory irritation or action: for it should not be forgotten, that structural lesions may also proceed from sub- action, or from conditions of vital power, and of vascular action, diminished as to grade, and mod- ified in kind from the healthy standard. Indiges- tion may therefore arise—(a) from depression or modification of the nervous influence; giving rise, 1st, to imperfect or disordered action of the mus- cular coats of the stomach ; 2d, to a diminished or modified secretion of the gastric juices; (b) from a morbid state of the mucus secreted by the follicular glands of the stomach, either connected with, or independently of, irritation (Embarras Gastrique of the French); (c) from inflammatory irritation and various organic changes; and, (d) sympathetically, from functional or structural dis- ease of adjoining or remote organs. 11. B. The observations now offered apply equally to the function of chylifaction, which, whilst it is often disturbed by inflammatory irrita- tion and organic changes, is as frequently disor- dered from modifications of the vital or the organic nervous influence supplying the duodenum, the small intestines, and their related organs, partic- ularly the biliary and pancreatic apparatus. When this influence is depressed, exhausted, or in other respects modified, then imperfect and irregular action of the coats of the duodenum and small intestines; deficient, or insufficiently elaborated, or otherwise morbid secretions from their internal surface, and from the liver and pancreas ; and alterations of sensibility, as well as of tonic con- tractility must be the result; whether organic change be superinduced or not; — such change most commonly being the remote consequences of neglected and long continued functional disor- der, or of its repeated reproduction by the numer- ous agents which occasion it. As respects chyli- faction, the result must be an imperfectly formed chyle, which undergoes the further process of assimilation either with difficulty or insufficiently, occasioning various disturbances or diseases, ex- pressed chiefly in the secreting or depurative vis- cera, as well as in the body generally. Also, when the vital influence is insufficiently exerted on the organs of chylifaction, the materials on which they act, more readily assume those combinations to which their chemical affinities, assisted by warmth and moisture, dispose them. But when their vital energy is duly exerted, the secretions poured out by the glands and surfaces, and inti- mately mixed with the ingesta from the com- mencement of mastication, are so far imbued with that influence which pervades the ceconomy, and converts other substances into those structures, with which it is itself so intimately associated, as to withstand purely chemical affinities, or to change them into such as are strictly vital. And as this controlling and self-perpetuating power is more and more weakened, so are the purely chemical forces more strongly exerted, until vari- ous new combinations, either of a gaseous or of an acid or acrid nature, are formed, whereby the digestive tube is inordinately distended, irritated, and, ultimately, permanently changed in structure, capacity, and even in position. DIGESTIVE CANAL — Functional Disorders ok. 539 12. C. The processes of facation, although obviously and most severely disturbed by in- flammatory irritation and organic changes, are also impeded or otherwise disordered without any such lesions. A deficient exertion of the vital endowment, through the medium of the organic nerves supplying them, or alteration of their sensibility, and the resulting modifications in the tonic and insensible contractility of their muscular coats, and in their exhaled and se- creted fluids, are even more frequently the causes of disorders in the functions of defalcation than appreciable organic change ; and even when this latter becomes developed, in this part of the canal as well as in others, it is still more frequent- ly the consequence of neglected and continued functional disorder. (See Constipation.) 13. iii. Morbid States of Sensibility of the Di- gestive Canal. — These states consist chiefly of pain in various grades and modifications. Acute, lancinating, dull or heavy, gnawing, burning, pun- gent, remittent, periodic, &c; and, whilst they are often attendant upon, — particularly burning or gnawing pain, — rather than occasioned by, organic lesions, especially of the external tunics of the canal, they are still more frequently un- accompanied by any appreciable change. Indeed, the numerous alterations of texture found in the gastro-intestinal mucous and sub-mucous tissues are seldom attended by severe pain. M. Andral very justly remarks that the mucous coat may be acutely, or chronically diseased — may be inflamed, thickened, softened, or deeply ulcerated —without any uneasy sensation, or, at most, with griping pains on going to stool. The abdomen of persons, whose intestines are ulcerated during adynamic fevers, may be even pressed in all directions, without the sensibility being painfully excited, unless the ulcers extend in depth to the peritoneal surface. On the other hand, the ali- mentary canal is frequently the seat of the most severe, or even excruciating pain, without its texture being at all affected, as proved not only by post mortem examinations, but also by its causes, its sudden accession and departure, and by the juvantia and laedantia. 14. A. The stomach is the most prone of any part of the digestive canal to experience changes of sensibility, probably owing to the numerous agents, chiefly ingesta — solid and fluid — hot and cold — bland and relaxing — exciting or irritating — depressing or inflaming — indigestible or unwholesome — to which it is subjected during life ; and often to all these, in hurtful variety and inordinate quantity, producing opposite im- pressions on, with extraordinary distension of, its coats. Add to the above, the various passions and emotions which disturb the nervous and cir- culating systems, and the reasons wherefore the stomach manifests not only the simpler states of indigestion, but also the severe and complicated forms characterised by altered sensibility, dis- ordered action of the muscular coats, and morbid secretion — as cardialgia, flatulency, acid and acrid eructations, pyrosis, rumination, bulimia, gastrodynia, and cramp or spasm, will be appa- rent. These, although sometimes associated with organic change, rather than occasioned by it, are most commonly referrible merely to modifica- tions of vital and nervous power and altered sen- sibility — pathological states, however, which will often superinduce organic changes when pro- longed, or aggravated by injudicious treatment and diet. 1 -5. B. The small and large intestines also ex- perience very remarkable changes of sensibility, often without any manifest lesion of structure, but generally in connection with irregular action of the muscular tunics, diminished secretion and exhalation, and an increased production of flatus. The different forms of colic — the flatulent, hys- teric, lead, Madrid, bilious, or the dry belly-ach, &c. — are the most marked examples of this state of functional disorder, which may, however, ter- minate in, or be complicated with, various alter- ations of texture, or of position and capacity. 16. iv. Disorders of Secretion and Excretion. — The secretions and excretions of the digestive tube are disordered in various ways, and often to a very considerable extent, without much general disturbance being the result. — A. When the nervous influence of the stomach, and occa- sionally also of the duodenum, is suddenly im- pressed or seriously disturbed, nausea and vomit- ing, with increase of the secretions of these visce- ra, are often, although not always, or even gener- ally, produced. Such disorder may depend on the state of the stomach ; on disease of the small intestines, especially of the duodenum ; on ob- structions in some part of the canal; on affec- tions of distant organs, as the nervous centres, the kidneys, the uterus, &c.; on intense im- pressions made upon any part of the frame, or on severe affections of the whole system. Even when vomiting is occasioned by a morbid state of the stomach itself, it is as often the result of an altered condition of nervous influence, as of structural change ; although in many cases both pathological states co-exist. This act may arise not only from irritating or injurious sub- stances taken into the stomach, but also from similar matters absorbed or introduced into the circulating current, and from morbid secretions poured out from its own villous surface, or regurgitated into it from the duodedum. Ingesta of the most op- posite kinds — whether highly stimulating and irritating, or depressing and septic, or simply re- laxant — may occasion it ; the stomach evincing in either case the disposition to eject whatever is injurious to the frame ; the retching often con- tinuing long after the noxious matter is thrown off, apparently in consequence of the morbid impression made by it upon the nerves supplying the organ, and through their channel upon the vital manifestations of the body. Vomiting from irritating or injurious matters in the circulation, arises most probably as much from the effect produced by them on the vital endowment, espe- cially as manifested in the organic nervous system, as from their effect upon the stomach itself through the medium of the blood circu- lating in it. Indeed, Ma jendie has shown, that attempts at vomiting will follow from this cause, even when the stomach has been re- moved from the body. In delicate persons, the sight even of certain substances, or the odour of others, particularly if they at any time had overloaded, or disagreed with, the stomach, will produce nausea and vomiting. The repeated retchings supervening with the collapse conse- quent upon excesses is probably favoured by the morbid and accumulated secretions generated 540 DIGESTIVE CANAL —Lesions of Circulation. during the excitement and the nausea following it. In this case, the vomiting is attributable chiefly to the exhaustion of the nervous in- fluence of the organ, and to the affection of the nervous centres ; a moderate repetition of the stimulus, or of some analogous excitant, re- moving the disorder. Seasickness is, however, the most conclusive illustration of the frequent origin of vomiting in modifications of the nervous influence These facts, as well the effects of irritation of the uvula or pharynx, and of in- flammatory affections of the brain, and other remote viscera, warrant the conclusion that vomiting is chiefly a nervous affection ; and that, although it is frequently attendant upon, it is often also entirely independent of, change of structure, either of the stomach, or even of any other part. (See Vomiting.) 17. B. Owing to the superabundance, or the irritating nature of the secretions formed by the intestinal villous surface, or to the quantity or quality of the biliary and pancreatic secre- tions, or to both pathological states conjoined, diarrhoea, lientery, or dysentery, may take place, independently of organic lesions and even when such lesions exist, it is generally to the co- existence with them of increased or morbid se- cretions proceeding from one or more of these sources, that these diseases are to be imputed. Even in cholera, in which the eruption of an increased quantity of morbid secretions into the duodenum occasions copious discharges from the stomach and bowels, with cramps, &c, we are not justified in concluding that any organic change is present beyond simple irritation, of a temporary kind, excited in the villous surface by the acrid state of the secretions passing along it. 18. II. Lesions of the Tissues compos- ing the Digestive Canal.—The difficulty of distinguishing between the slighter lesions of structure, and changes occurring shortly before and after death, as well as states of the villous membrane connected with the conformation and diathesis of the individual, has already been pointed out. More frequently, however, no such difficulty exists, the change being of a kind that will not admit of a doubt as to its nature. But in judging of very many of these more pal- pable lesions, we shall fall into numerous errors, if their more prominent appearances merely be considered, without reference to their causes, and to the state of vascular action which occasioned them, and to the conditions of vital power with which the vascular action was associated. For various changes of a remarkable description, closely resembling each other, may arise from very different states of vascular action and of vital power — either from sthenic inflammation, or increased organic action of the tissue, or from sub-action or diminished organic action, or from perverted nutrition of the part. To ascertain the nature of the morbid process, therefore, which gives rise to very manifest lesions, from even the closest examination of these lesions themselves, is frequently a matter of difficulty, and often of impossibility, in the present state of our knowledge ; and it is chiefly by connecting them, as far as we may be enabled, with their causes, and with the conditions of vital power and of vascular action, that we can approach to accurate views of their nature. This I have attempted to do more fully and appropriately in the article Inflammation ; and have on y re- ferred to these important and too much neglected pathological states, when the nature of the changes required that they should be briefly noticed. , , 19. It should be understood that the several lesions about to be noticed, may exist either separately, or variously associated the one with the other; in some cases, in the same part of the canal, and holding the relation of cause and effect; in others, in distinct or remote parts, and without any such connection. As it will, how- ever, be impossible to describe the changes ob- served in this part, in their numerous states of association, they will be considered separately, but with reference to such of these states as are most common. I shall, conformably with this plan.notice—;first, changes of vascularity; second, lesions of the tissues composing the canal; third, lesions of internal secretion, comprising adven- titious productions; and, fourth, changes of ca- pacity and position. 20. i. Changes of Vascularity, or Lesions of Circulation. — A. Anamia, or diminished vascu- larity of the digestive canal is sometimes observed; extreme paleness, existing either throughout, or in parts only. It is usually attended by more or less attenuation of the gastro-intestinal parietes; and is most frequently met with in subjects that have died from the exhaustion of chronic dis- eases, or after severe fevers. In these cases, ulcers are often found co-existent with it, that are as pale and bloodless as the surrounding tissue. This association of anaemia with asthenic ulceration is not infrequent in children who have suffered from chronic diarrhoea and lientery, with or without mesenteric disease, and who have died comatose. Anaemia of the digestive canal is also observed in cases of fatal haemorrhage from other organs. 21. B. Increased vascularity, not arising from the causes stated above (§ 3, 4.), but from ex- cited organic action, is of extremely frequent occurrence. As it is generally confined to the villous membrane, the canal externally will often exhibit no appearance of it, or will even be unusually pale ; for sometimes, when this membrane is intensely red, the subjacent cel- lular tissue even, and the rest of the tunics, are quite devoid of colour. It is owing to this circumstance chiefly, that the existence of in- creased vascular action in cases of bowel com- plaints has been, until recently, so much over- looked amongst pathologists. This connection of inflammatory injection of the villous coat with disorders of the digestive tube had not, however, entirely escaped the observation of Gi.isson, Baglivi, Morgagni, L. Bang, and C. Smyth, and was afterwards placed in its true light by Pinel, Baillie, Marcus, Hilden- brand, Abfrcrombie, Latham, Andral, Gendrin, Billard, and others [See Refer.]] whilst Broussais and his followers made it the basis of a pathological doctrine, and stretched it beyond its legitimate limits. 22. Increased vascularity may be seated chiefly or separately in the villous membrane itself, or in its villi, or in the follicles either dis- seminated through or aggregated in it, or it may affect two or all of these anatomical elements DIGESTIVE CANAL —Lesions of its Tissues — Atrophy. 541 simultaneously.—(a) When the membrane itself is injected or inflamed, the appearances are di- versified ; but at first the light can still be par- tially seen through the coats, the vessels being disposed in a finely arborescent form. Some- what later, the opacity is complete; the redness being at the commencement in spots, stars, patches, streaks, or bands ; and of a rose or florid colour; but afterwards more deep, and dark or purplish ; and terminating either insen- sibly or abruptly.—(6) When the villi are in- flamed, the internal surface presents a number of red points, which are often closely crowded to- gether, rendering the membrane opaque. Upon a close inspection, these points are found to consist of the villi ; their injection occasioning the change of colour, which is either limited to their summits, or is extended from thence to their bases. In some instances, the injection is alto- gether confined to the villi; in others, the mem- brane itself is also more or less affected. In many cases, the villi are of a brownish or even blackish colour, particularly in persons that have had chronic diarrhcea. Active injection of the villous membrane may thus exist in an acute or chronic state, without any furthur change, for periods of very variable duration. In some cases, k will terminate in softening or ulceration in a few days ; and in others, signs of irritation may exist for a very long time, and still simple injection without change of structure will only be found. —(c) When the follicles are the seat of increased vascularity, the injection is in the form of a small circle or areola, consisting of interlaced capillary vessels, with slight elevation of the membrane of the part, owing to the injection of these vessels and the tumefaction of the follicle. Often a smaller red circle is placed within the preceding, and situated, as M. Andral supposes, in the margin of its orifice. Sometimes the situations of the follicles present both these in- flamed circles quite distinct; at other times they both increase, and at last meet each other. In some cases, instead of these reddish circles, brownish or blackish circles, similarly disposed and elevated, are met with. In other instances, where this disposition of the injected vessels is observed, there is neither tumefaction within the circle, nor depression in the central red point, to indicate the existence of a follicle. Inflamma- tion of the follicles of Brunner and Peyer has recently attracted great attention owing to the writings of Bretonneau, Trousseau, and others on the subject (see the Bib. and Refer.). 23. Increased vascularity of the digestive canal is seated either (a) in the arterial and other capillaries, (b) in both the capillaries and venous trunks, or (c) in the larger vessels only. The first of these is an undoubted evidence either of irritation or of incipient inflammatory action, if no further lesion exist. The second may belong either to these pathological states, or to congestion, of a morbid kind existing during life, or of a mechanical nature occurring after death. The third may be the indication of pre-existing inflammation, partially subdued, or of increas- ed determination of the circulation to the part. It is of importance to recollect, when judging respecting the nature of increased vascularity observed in the digestive tube, that, when it arises from augmented organic action, it com- 45 mences in the capillaries and extends to the larger vessels, — the former only being found in- jected after death, in many instances ; whereas, when it proceeds from passive congestion, it begins in the large veins and extends to the ca- pillaries—the former only sometimes continuing injected after dissolution. When the vascularity is active, it commences generally with a capillary or reticular injection, which increases until an uniform red tint takes place, and every trans- parent interval disappears, owing to the crowded state of the injected capillaries. As the vascu- larity declines, it again assumes the reticular form, and at last only some large vessels are observed in an injected state. 24. Can the colouring of the part be an index of'aprimary chronic, or oCaconsecutively chronic, state of inflammation, or of an acute inflamma- tion which has supervened on the chronic ? An approximation only to the truth can be made in answering these questions. M. Andral sup- poses that the brown, grey, and slate colours especially belong to chronic irritation. But sub- stances taken into the stomach, and proving quickly fatal by the extensive and intense irri- tation they occasion, or by their noxious impres- sion on the nerves of organic life, or by both modes of action, usually impart a brown, dark, or purplish colour to the injected villous surface. The inflammation also of this surface, in adynamic fevers, is often of a very dark ochry or brown colour; and the asthenic forms of inflammatory action, as well as many of those in which the blood is contaminated or otherwise morbid, frequently present similar hues. Also a red colour may attend chronic as well as acute inflammatory action, although much less frequently. The above lesions of circulation are generally fol- lowed, after a longer or shorter time, according to the state of vital power, the condition of the circulating fluid, and intensity of action, by a change, to a greater or less extent, in the vital cohesion, and tonicity of the tissues com- posing the paretes of the canal, giving rise to the alterations of texture about to be described. 25. ii. Lesions of the tissues composing the Parietes of the Canal.—A. Atrophy may affect only one, or all the coats of the gastro-intestinal parietes.—(a) Atrophy of the villous membrane presents several grades: in a less degree, or at its commencement the villi are greatly diminished, or nearly or altogether effaced. In a more ad- vanced grade, not only have the villi disappeared, but the membrane itself is remarkably attenuated. In some cases, the villi are obliterated in places, and not in others. In the situation of cicatrised ulcers they are always absent. Atrophy of the villous membrane is met with chiefly in chronic cases, similar to those in which anaemia has been stated to occur; and it is obviously in some cases a post mortem change. It is often a con- sequence of anaemia ; but it may accompany ulceration, vascular injection, or other lesions of the digestive canal.—(b) The muscular coat may also be atrophied, so that its fibres become much less apparent, the fasciculi wasted and separated by wider intervals, occupied by cellular tissue, from which they can hardly be distinguished. Atrophy of the muscular coat most frequently co-exists with atrophy of the other tunics, but it may also occur when they are hypertrophied, 542 DIGESTIVE CANAL —Hypertrophy of its Tissues. especially when the sub-mucous cellular tissue is much thickened.—(c) All the coats of the di- gestive canal may be co-existingly atrophied, the parietes of the canal being then remarkably at- tenuated, and appearing to consist merely of a sero-cellular tissue, which is transparent and colourless, and apparently without villi, follicles, or blood-vessels (Andral, Louis, Billard, &c). This change is only met with in any con- siderable degree in parts of the tube ; most fre- quently in the splenic portion of the stomach, and lowest third of the ilium. 26. B. Hypertrophy, or thickening, of the pa- rietes of the alimentary canabnlay be confined to a single tissue, or may simultaneously exist in all the coats of which they are composed. This change, when far advanced, or seated in the sub- mucous tissue, and particularly when associated with ulceration, has been often mistaken, until recently, by British pathologists for scirrhus, and by Continental writers for true cancer. Al- thorgh thus generally misconstrued, it appears to have been better understood by Rudolphi (Bemerkungen, th. i. p. 35.) and Thilenius (Med. u. Chir. Bemerk. i. p. 202.). 27. (a) Hypertrophy of the villous or mucous membrane consists of an increase of its density as well as of its thickness, and is thereby distin- guished from the slight tumefaction produced by inflammatory injection of its capillaries, and from tumefaction and softening, with more or less discolouration, occasioned by acute inflammation, or intensely irritating ingesta. — a. When really hypertrophied, the villous coat may be removed in large shreds, which are harder as well as thicker than natural. When thus altered, it rarely retains its natural colour, but commonly presents either various shades of redness, or a slate coloured, or a brownish, or blackish tint. This lesion is most common in the stomach; next in the rectum, caecum, and colon ; and least so in the small intestines. It may exist throughout either of these viscera, or in parts or points merely. When the membrane is thickened in the whole or greater part of the viscus, it may be either smooth, or unequal ; in the latter case it usually presents a number of elevations separat- ed by depressions, giving it a mammillated or papillary appearance. When the hypertrophy is only in isolated spots or points, it may pro- ceed so far as to produce various elevations, patches, projections, tumours, and polypous growths, with or without narrow pedicles, and which have often been mistaken for fungous or malignant formations ; but which, when pro- minent, are more appropriately termed vegeta- tions or excrescences. They have been described byBARTHOLiNus,VAN derWiel (cent. i. obs. 56.), DeHaen (Rat. Med. vi.cap. 4.), Bauer, Schaarschmid (Med. u. Chir. Nachrichten, b. v. obs. 10.),Sandifort (Observ. Anat. Pathol. 1. i.,etMus. Anat. i.p. 255.),PoRTAL(-dnaf,.ZUeU t. v. p. 243.), Baillie (Ser. of Eng. fyc. fuse. iv. pi. 6.), Stark (Archiv. b. i. st. iv. n. 3.), Rebikre (Journ. de Med. t. Ixiv. p. 619.), Andral, and others. These excrescences mav either be of the usual consistence and colour of the mucous coat, or they may be harder or softer. They may also present every shade of colour ; and be either nearly bloodless, or remarkably vascular. In some cases, their capillary vessels are so numerous or interlaced as to impart to them an erectile appearance; in others, their veins are large and engorged so as to resemble the morbid productions described hereafter (§ 48—51.). They have bases of various extent; in some cases large, in others very narrow, or slender pedicles; their summits being either pointed or rounded, or broad, resembling a mushroom. They are found in every part of the gastro-intestinal surface ; in the cardiac and pyloric orifices, or any part of the stomach ; in the caecum, in the commencement of the rectum, in the colon, and least frequently in the duodenum and small intestines. About the anal orifice, however, and inferior part of the rectum, they are very common, and are there often produced by the syphilitic virus. Their number varies from one to twenty or more. M. Rullier preserved a stomach which was studded with about eighty, each of the size of a filbert. They may exist simultaneously in different portions of the digestive canal, as in the stomach and caecum. 28. S. These excrescences should not be con- founded with hypertrophy occurring in some of the villi with which the membrane is provided. When much enlarged, the villi project further, and are of a whiter colour, than the rest of the surface ; and form small cylindrical vegetations, which may be readily distinguished from ex- crescences of the mucous coat itself. 29. y. The villi, however, are much less fre- quently hypertrophied than the follicles. When the digestive canal of adults is studded with very apparent or projecting follicles, we may consider these bodies as diseased, although they may not be really hypertrophied. When they participate in the increased vascularity of the inflamed mucous coat, they become tumid from this circumstance, or from the morbid secretions collected in them, but not truly enlarged. When the aggregated follicles are tumified, ele- vated patches are thereby formed, giving rise to the Dothinenteritis of M. Bretonneau. How- ever, as M. Andral has remarked, when thus tumified from increased organic action, their nu- trition is often thereby augmented, and they then continue enlarged, or even increase in size, after the morbid vascularity has disappeared, and are then truly hypertrophied. When thus changed, they consist chiefly of small, conical, hard, whitish bodies, with central orifices. This lesion is met with often in persons whose digestive functions had not been disordered, as well as in those who had experienced either acute, chronic, or recurring diarrhcea. But hypertrophy of the follicles may also arise without any signs of an- tecedent increase of vascularity either in them, or in the villous membrane itself. When this has been the case, the only disorder has been either constant, or recurring diarrhcea; but as often no ailment has been complained of. En- larged follicles may have their orifices of the natural size, or widened so as to be mistaken for a small ulcer, or narrowed and even obliterated. When this latter occurs, the follicle becomes distended by its secretion, in some cases, to such an extent as to form large globular tumours. The parietes of the hypertrophied follicle may also be transformed into a fibrous, or fibro-car- tilaginous, or even a cartilaginous tissue, thereby augmenting their thickness, — a change jutflj DIGESTIVE CANAL — Hypertrophy of its Tissues. 543 imputed by M. Gendrin to chronic inflamma- tion. Hypertrophy of the follicles is most com- mon in the inferior part of the ilium, in the caecum, in the rectum and colon, and in the duo- denum, but is rarely met with in the stomach. It is most frequently a consequence of diarrhoea, dysentery, and gastric fevers (which see); and may be mistaken for tufts of enlarged white villi, and for small white bodies, consisting of the rudiments of valvula conniventes. It is very common after the bowel complaints of children, amongst whom, however, the follicles are always more manifest than in adults. 30. (b) Hypertrophy of the sub-villous tissues may be more or less general throughout one of the principal divisions of the digestive canal, or it may be circumscribed. It is not unusual to find, after chronic diarrhcea or dysentery, the sub-mucous cellular tissue much more apparent than usual, or even two or three lines in thick- ness, in the colon or rectum, or both. It is then denser than natural, sometimes with more or less regularly arranged fibres, or plates, of a pale or pearly white colour, and without any evident blood-vessels. It is often of a homogeneous semi-cartilaginous-like texture ; but when thus generally enlarged and indurated, the hyper- trophy is never so great as when it is circum- scribed. When it forms, in some part of the canal, a tumour, elevating the mucus surface by its thickness, it constitutes the change to which the term scirrhus has been very generally applied, and differs from the diffused hypertrophy only in being circumscribed, and many times thicker. That the tumour occasioned by the circumscribed hypertrophy, whether existing in the cardia or pylorus, is not the result of the production of a new tissue, but arises from en- largement and induration—owing to excessive irri- tation—chiefly of the sub-mucous tissue, is man- ifest in the early states of the lesion. This may continue to be the only change ; but often ulte- rior alterations take place, and a new structure is developed; the part becomes vascular, is sometimes divided into lobes, and morbid secre- tions are poured into its substance, whereby it acquires the appearance of areolae and cells con- taining these secretions ; the fibriles of the cel- lular tissue between them becoming at the same time more and more hardened and hypertrophied. Frequently the hypertrophy is not confined to the sub-mucous tissue, but is extended to the tissue connecting the muscular and peritoneal coats ; hardened, white fibres running between and sepa- rating the fasciculi of the interposed muscular coat, and thereby connecting both layers of hypertrophied cellular substance. M. Andral considers these fibres to consist of the cellular tissue placed between the muscular fibres, also in a state of hypertrophy ; the latter structure gradually disappearing before the progressive in- crease and induration of the former. At last, all appearance of muscle is lost, and a mass either of simply hypertrophied and indurated cellular tissue, or of this substance further and con- secutively altered, chiefly by the deposition into it of morbid secretions, is placed between the peritoneal and mucous coats. 31. This lesion is generally the consequence of inflammatory irritation long kept up or frequently reproduced in the mucous membrane, which may be sound, no change of it having existed, or that which formerly existed having ceased. More frequently, however, it is either injected, indurated, softened, ulcerated, or en- tirely eroded in the hypertrophied part. Hy- pertrophy of the sub-mucous tissue is most fre- quent in the stomach and large intestines, par- ticularly the rectum, where it may be either diffused or circumscribed; and the least so in the small intestines, in which it is commonly cir- cumscribed. It is rarely met with in infants. MM. Billard and Andral have, however, ob- served it in them; and I have seen it in the colon of children a few years of age, who had long been affected with chronic diarrhcea. It seldom seen in the stomach before thirty; but it is common in this viscus between the ages of thirty-five and sixty-five, especially near the py- lorus and cardia. 32. (c) The muscular coat is sometimes hy- pertrophied, either alone, or along with the sub- mucous tissue. In the former case, the pyloric orifice of the stomach is its chief seat (Cruveil- hier, R. Prus, Louis, Bou ill aud, Andral, &c), and is much increased in thickness from this circumstance. In hypertrophy of the sub- mucous tissue, the muscular coat, instead of dis- appearing before the increasing bulk and indu- ration of the cellular tissue that surrounds and penetrates it, as most frequently occurs, and as above described, is sometimes also hypertrophied. In this case, when a section is made of the dis- eased part, the hypertrophied muscular coat may be traced, in the form of a bluish semitrans- parent layer, placed between two other layers of a whitish colour, consisting of the sub-mucous and sub-peritoneal cellular tissue also in a state of hy- pertrophy. This central or muscular layer is tra- versed by lines of the same colour as the layers on each side of it; the enlargement and indura- tion thus extending to the muscular coat, and through its fibres, by means of their interposed cellular tissue, to that connecting it with the peritoneum. This lesion is most frequent in the stomach, particularly near the pylorus, and con- stitutes, as well as the preceding states (§ 27.) — often with various alterations of secretion superadded — what is usually called scirrhus. (See Stomach — Diseases of.) 33. C. Hypertrophy of the nerves and vessels. — (a) The nerves supplying the gastro-intestinal canal are very rarely enlarged. M. Andral has never observed any such change in them. M. R. Prus, however, found, in a case of cir- cumscribed hypertrophy of the sub-mucous tissue and muscular coat (scirrhus) of a part of the body of the stomach, the right cesophagaean branch of the pneumo-gastric nerve increased to twice its bulk, from the cardia to its disappearance in the tumour. It should be recollected, that the state of the nerves is seldom enquired after in post mortem inspections, and that to ascertain the condition of the ganglial nerves requires the most minute research, which can seldom be devoted under such circumstances.—(6) The blood-vessels of the gastro-intestinal tube are very often large and dilated ; but this is not hypertrophy. Their parietes are very rarely thickened. M. Andral found, in two cases of chronic disease of the stomach, the parietes of the veins thus changed, constituting true hypertrophy. Forestus (06- 544 DIGESTIVE CANAL —Softening of its Tissui s. sens. 1. xviii.; Schol. adObserv. 18.) and Voigtel I vanished. In some cases of children, the soften- (Handb. der Pathol. Anat. ii. p. 95.) have no- ing exists only in a number of small round ticed a varicose state of the veins of the stomach; | patches of a red colour ; and in others, it is in a lesion which M. Andral has not met in his i lines, streaks, or irregular bands. It is probable numerous dissections.— (c)l he lymphatic vessels, I that the small softened spots which have been and especially the glands of the digestive canal, | also noticed by M. Lestii r may become ulcers are very frequently hypertrophied, if the increase from the extension of the lesion to the subjacent of volume so often found in the lacteal or mesen- i tissues. The colour of the softened villous coat teric glands after irritation of the intestinal | may be greyish or natural, or white with a bluish mucous surface be considered as true hyper- | tinge, or a dead milky white, or red, brown, trophy. But, in many instances, the enlarge- j brick red, and more rarely purple. Softening, ment is merely the consequence of vascular in- j with some one or more of these shades of colour jection, and serous or sero-puriform infiltration of I in different parts of the canal, is met with as a their tissue, without any increase of nutrition — the very element of hypertrophy. But after these pathological states have subsided, an evi- dent increase of the bulk and density of these glands remains, whether the primary irritation continues, or has long previously disappeared. When these glands are enlarged, dense, and not very vascular, we may attribute the change to increase of nutritition, according to the state of our knowledge of what constitutes it. Put when evident signs of inflammation — as increased vascular injection, redness, and tumefaction — are observed, the change must be chiefly im- puted to increased organic action of the blood- vessels; although this condition does not preclude consequence of various acute and chronic ma- ladies seated either in the digestive organs, or in remote viscera, especially chronic diseases of the lungs. White softening in the lower part of the small intestine and colon is one of the most com- mon lesions observed after chronic diarrhcea. 35. (b) Softening of all the coats of the diges- tive canal may take place to a remarkable extent, particularly in the stomach and bowel complaints of children, and in the gastric and adynamic fevers of adults. It has been described by Ja e g eh, Zeller,F. Rhades, Fleischmann,Laisne, Cruveilhier, Haviland, Wiesemann, Gairdner, and other writers referred to in the Bibliography. In some cases, the parietes of the the co-existence of hypertrophy ; with which, ; stomach may be torn with the utmost ease, all indeed, increased vascular action, in some grade j the tunics and interposed cellular tissue having or other, is very frequently, and even necessarily, become friable and semi-dissolved ; resembling, associated, and of which it is generally the j in extreme cases, a kind of jelly, without any cause. However, in many cases of what may j trace of organization, and hence denominated by be called hypertrophy, or, otherwise, enlargement j M. Cruveilhier "gelatiniform softening." In of the lacteal or absorbent glands, instead of i some of these cases, the gastro-intestinal parietes being more vascular, they are pale, and even are modified only in respect of consistence, and more bloodless and colorless than natural, par- i have the outward appearance of being sound, ticularly after chronic diarrhcea, lientery, and until more closely examined. With this loss of marasmus. The glands through which the Iv m- vital cohesion, the colour of the part may be phatics of the stomach pass are not so frequently either natural, or remarkably pale, or red, and enlarged as those of the mesentery. Often, how- without reference to the acuteness or chronicity ever, those along the curvatures of the stomach of the disease. The splenic portion of the sto- and around the pylorus are much increased in j mach is most liable to general softening of size. , the coats; but it also occurs in the small intes- 34. D. Softening of the digestive canal is one tines, and the caecum and colon. M. Andral of the most common changes observed ; and it states, that he met with reddish softening of may be limited to one of the coats, or extended the coats of the stomach in a child who had to two or all of them. In this latter case the [ taken sulphuret of potash before death. I be- parietes of the canal may be torn with the ; lieve that this substance, as well as the caustic greatest ease.—(a) Softening of the villous coat : alkalies, will readily occasion this change, if is most frequently met with : it occurs in every j exhibited in too large doses, or continued too degree, and either throughout or in parts of | long. As to softening of the gastro-intestinal this membrane only, the consistence of the other coals being undiminished. This lesion is most common in the stomach, where it has been most minutely studied. In its first stage or grade, it can hardly be removed in shreds, as it may be in the healthy state ; and it is readily converted, by scniping, into a kind of pulp. As the softening increases, the slightest touch reduces it to a mucous-like pulp ; and at still further advanced periods, it is either no longer uniformly spread over the gastric surface, or it is entirely deficient in parts or throughout, leaving the sub-villous tissue quite bare. This lesion may exist in the whole of the stomach, or in parts of it only, — most frequently in the splenic portion. It is often attended by marked dilatation of the veins running between the coats, evincing the ante- cedent existence of increased vascular action in cases where other appearances of it may have parietes ever being a post mortem change, this pathologist remarks, that it n.av be established as a general principle, that aiiy softening ob- served on opening the body at the usual period after death should not be considered as the result of putrefaction. But it may be, when observed in the stomach, the result of the action of the gastric juices, as shown by J. Hunter and others referred to. It is, moreover, extremely probable that the acrid and morbid secretions of the dis- eased gastro-intestinal mucous surface may so far act upon any part of it as to soften and to erode it during the latter hours of existence, and the time that elapsed after dissolution. These infer- ences have received support from experiment and pathological observations (§ 6.). Dr. Ca- merer, of Stuttgard, made, in 1818, a number of examinations with a view to the solution of this question : and found that, in all the animals DIGESTIVE CANAL — Ulceration of its Tissues. 545 which had been killed while in good health, the great extremity of the stomach was softened, and if a sufficient time had elapsed, its parietes were dissolved or even perforated ; no signs of putre- faction being observed. Whilst, on the contrary, in a dog already evincing putrefaction, no trace of softening existed in the stomach. This phy- sician also found that the fluid collected in the stomach of two children who had died of gela- tiniform softening of this viscus, introduced into the stomach of a man just dead, produced, at the end of twelve hours, solution of the coats of the part with which it had come in contact; that a portion of the same fluid had no effect upon the stomach of a living rabbit ; but as soon as the animal was dead, or when the pneumogastric and trisplanchnic nerves were divided on each side, this fluid had an immediate action on the coats of the stomach. Hence it must be concluded that softening of this viscus is not unfrequently a post mortem change. It ought to be remarked, that softening of any part of the digestive canal has been too generally imputed to inflammatory irritation, owing to the frequency of its occur- rence in febrile and inflammatory diseases, and from the action of acrid poisons. But the extreme cases of it that I have had an opportunity of observing, have been the choleric fever and diarrhoea of infants occurring after weaning, and in children who have died from aqueous effusion on the brain. In most of these it was unattended by vascular injection ; the softened parts them- selves, and those surrounding them, being either softened merely, or also attenuated or even eroded and perforated, and quite pale, excepting in the course of a few large vessels. I have likewise observed it, but in a different and more general form, in the adynamic and deliquescent states of remittent and continued fevers,* aud in two cases of puerperal disease ; the softened parts being more or less discoloured, and sometimes ulcerated, but not perforated. From the condition of vital manifestation in the cases in which 1 have re- marked this change, it may be inferred that it re- sults chiefly from a loss of the organic nervous power, and of the vital cohesion of the tissues pre- viously to death, but is increased by this event, and by the acton of the morbid fluids and secre- tions upon them. 36. F. Ulceration of the gastro-intestinal pa- rietes is a frequent and important lesion, and has long attracted much attention in practice. It seems to have been first noticed by Avicenna (Canon. 1. iii. fen. 16. tr. 1. cap. 2.), who often makes mention of excoriations and ulceration as a cause of vomiting and diarrhoea ; and it has been described by Bonet (Sepulch. 1. iii. sect. xi. obs. 2, 3, et passim.), Gmelin, Friend, Hal- ler, Field, Penada, Baillie, Frank, Prost, Andral, and others (see Bibliog. and Refer.). It is met with in the parts of the canal in the following order in respect of frequency :— The inferior third of the ilium, the caecum, the colon, the rectum, the upper two thirds of the ilium, the stomach, the jejunum, and the duode- num. In either of these situations it is a conse- quence — (a) Of softening of the villous coat, * f should state, in support of my own originality as to this change in fevers that it was noticed in a paper read by me to the London Medical Society in 1819, and pub- lished in the Quarterly Journal of Foreign Medicine for Jan. 1831. without any evident injection, the ulcer being formed in the centre of the softened part ; — (6) Of small inflamed spots of the villous membrane, which is quite sound in the intervals between them;—(c) Of a general injection or inflammation of this membrane, the intervals being more or less red;—(d) Of the sloughing of circumscribed parts of the villous, and sometimes of the sub-villous, and even of the muscular tissues;—(e)Of a change in the mucous follicles, either the isolated, or Pey- er's glands, or of both,—generally preceded by obstruction and enlargement of them. These glands first form conicle knobs, and are either few or numerous, greyish or reddish, and with or without areolae (§ 22. c). Subsequently, a slight depression appears on their summits, owing to enlargement of their orifices, or to an incipient ulcer; this depression gradually becoming more considerable; the tumid glands thus resembling, particularly in their inflamed state, and when they contain a small quantity of puriform matter, the dimpled pustules of small-pox. They were formerly considered identical with these pustules, particularly when found, as is occasionally the case, in that disease; and they have been de- scribed as such by Fern el (De Abd. Rer. Causis, 1. ii. cap. 12.), BAiLLOu(£,pirf. et Ephem. I. ii. p. 207.),Horstius (Instit. Med. Disp. 3.), A. Pare (I. xiv. cap. i.), Peyer (Observ. Anat. ii.),MEAD (De Variol. fyc. Lond. 1747, p. 323.), Bartholin (cap. iii. obs. 29.), P. Fabricius (Observ. circa Const. Epidem. Ann. 1750, § 18.). Pustular ulcers have been particularly noticed in chronic dysentery, by Sir J. Pringle, Sir G. Baker (Epid. Dysent. of 1762.),Sir G. Blane, and Dr. D. Monro; the last of whom describes the black colour of their bottoms in that dis- ease. These pustular or pimple-like excrescences are often destroyed from the apices to the bases, leaving circular and deep ulcers in their places, that sometimes extend or run into one another when the aggregated follicles are affected, and thereby produce large, irregular, ulcerated patch- es. Ulceration originating in the follicles may proceed either from inflammatory action, or from 1 obstruction of their outlets, and their consequent distention and irritation by their natural secretion, which had become acrid from the retention, or by the accumulation of a morbid or tuberculous like matter, which imparts to them the appear- ance of white granules ; this change being suc- ceeded by ulceration, often without any apparent increase of vascularity.—(/) Ulceration nay also arise from disease of the sub-villous tissue, instead of commencing in the villous coat itself, as in all the preceding states. In this case the sub-villous tissue is the seat of various morbid secretions—as of tuberculous matter—which irritate the villous coat, inflame it, and at last ulcerate it; or which, by interrupting the connection of a portion of this coat with the parts beneath, cause it to sphace- late, leaving an ulcer-like excavation in its place. 37. Ulceration of the digestive tube is — or rather is an attendant upon — either an acute, or a chronic, disease,—more commonly the latter. It is very rarely acute in the stomach, but is more frequently so in the small and large intestines. The number of ulcers is various — from one to some hundreds. They are generally only few, or even single, when they occur in the stomach; and very numerous, crowded together, and con- 546 DIGESTIVE CANAL —Perforations of. fluent, in the ilium and large intestines; in which latter, however, they are sometimes met with singly, or few in number, and isolated. Their form is usually round or oval; but they are also sometimes linear and irregular. They are most frequently seated on one side of the canal, but they may occupy its circumference. Their mar- gins are either white, pale, red, or of deep brown; the portion of villous membrane forming them, being either of natural thickness and consistence; or softer, harder, thinner, or thicker. In some cases the surrounding sub-villous tissue is thick- ened and indurated. Their bottoms consist of different tissues, according to the depths to which they may have penetrated. In some instances they are so slight as to appear like abrasions or excoriations; and in these the mucous coat still remains at their bottoms, the villi only having been destroyed. More commonly, however, the villous coat is penetrated; the sub-villous tissue, which is usually either grey, red, brown, or blackish, soft and fungous, or hard and scirrhous, forming the bottom of the ulcer. In other cases, neither the surrounding villous membrane, nor the cellular tissue below it, is further altered than as regards the solution of continuity, and some- times diminution of consistency, the bottoms and margins of the ulcers being white, pale, without inflammatory appearances, and occasionally re- markably softened. These alterations are com- mon in the stomach and bowels of children who have suffered diseases of these organs, or of the brain, after weaning ; and in adults who have died of pulmonary maladies, or of bowel complaints after fevers. Dr. J. Gairdner considers that they are not true ulcere, but erosions of portions of the coats which were | previously diseased, by the juices of the organs after death. I have seen many of these cases, chiefly in children, and believe that the principal part of the change must have taken place pre- viously to dissolution, which had most probably rendered the surrounding tissues less vascular, and further diminished their already weak cohesion, long before the period at which these changes usually supervene (§ 35.). 38. As the ulcers deepen, the sub-mucous and the muscular tissues are successively penetrated, and in some cases without any appearance of vascularity in either the bottoms or the mar- gins of the ulcers, or in the intervals between them ; these latter cases generally occur in the diseases already alluded to, and in cases of great asthenic or vital depression, sometimes associated with anaemia or a cachectic habit of body; the ulcers assuming a truly phagedenic character. When the»peritoneal coat is reached, it is either thickened, by a developement of the cellular tissue connecting it with the muscular coat; or it is inflamed, the vascular injection being evident, and sometimes attended by an effusion of lymph, on its free surface, giving rise to partial adhesions between it and the opposite parts. In other cases, particularly in the asthenic ulcers now noticed, the peritoneum at their bottoms is thin, transparent, and pale; no coagulable lymph being thrown out upon its free surface, owing to the weak and ca- chectic state of the frame. A single small ulcer may penetrate deeply, and perforate the intestine; whilst a similar result may not arise, although the ulcerations are both numerous and large. 39. The coats in the intervals between the ulcers, as well as the parts immediately sur- rounding them, may be of natural co our, con- sistence, and thickness ; or more or less either softened, injected, tumefied, thickened, or hyper- trophied, and variously coloured. The interve- ning villous surface is often of healthy colour, but softened, and studded with enlarged follicles; and although it is more frequently slightly in- jected, yet, in some cases, the opposite condition already noticed obtains. The sub-villous tissue is often more or less thickened and indurated where the ulcer penetrates the villous coat, the ulcer appearing in the centre of a thickened or hypertrophied mass. The cicatrisation of ulcers has been observed by Baldinger (N.Magazin, b. ii. p. 347.),Male, Abercrombie,Anpral, Trolliet, Billard (see Bib I. and Refer.), and others. A large cicatrised ulcer was found in the stomach of M. Be c lard, who had long experienced disorder of this organ. Andral refers to several cases, in two of which the mu- cous membrane was evidently reproduced. The changes that take place on the peritoneal surface, when it becomes the bottom of the ulcer, as well as when it is perforated, have a marked reference to the state of vital power; under usual circumstan- ces, and in a sthenic state of the system, the adhe- sions already noticed take place; but in an asthen- ic habit of body, coagulable lymph is not produced, or not in such a state as to form adhesions; and often merely an aqueous or turbid fluid is exhaled; sometimes long before the ulcers have penetrated far through the parietes of the canal. Thus as- cites may supervene in any of the stages of ulcer- ation, as observed by Prost (Mid. Eclair, par I'Ouver. des Corps, t. ii. p. 52.) and others. 40. G. Perforations of the digestive canal have recently attracted much attention; but they had not passed disregarded in former times. Among the numerous writers of the 16th, 17th, and 18th centuries, who have noticed this lesion, a very great proportion, having observed it asso- ciated with intestinal worms, imputed the per- forations to them, — an inference not confirmed by more accurate modern research; the worms having merely passed through the openings they found ready made. Instances, however, of tins lesion unassociated with the entozoa have been recorded by Morgagni (Epist. xxxi. art. 2.); Monro, Vetter (Aphorismen, frc. b.i. p. 193), Bang, Hunter, Gerard, Portal, Bres- chet, Laennec, (Journ. deMtd. Cont. vol. iv. p. 557.), Percy (Ibid. vol. iii. p. 510.), Lerocx (Ibid. vol. xv. p. 239.),Penada, Jaeger (Hufe- land u. Himly. Journ. d. Pr. Heilk. May, 1811.), Gistren (Ibid. July, 1811.), Marcus (Epht- meriden der Heilk. b. i. heft ii.),CLoo.u ET(iVbu». Journ. de Med. t. i.),Louis (Archives Giner. frc. t. i. p. 17.), Legallois (Ibid. vol. vi. p. 68.), Chaussif.r, Rullier, Ebermaier, Gaird- ner, Abercrombik, Armstrong, &c. (see Refer, in Bibliog.). This lesion may arise in va- rious ways : (a) It may be partly or altogether a post mortem change, and attended by softening and thinning of the surrounding tissues; (6) or it may be caused by an eroding ulceration of the tu- nics, without injection, but with softening and thin- ning of the margins; (c) or by a circumscribed slough involvmg all the gastro-intestinal tunics; (d) or by an nicer that has penetrated all the DIGESTIVE CANAL—Perforations of. 547 coats; (e) or by rupture of a previously softened or otherwise diseased portion of the parietes. 41. (a) Perforation from the action of the gastric juice is always in the depending part of the stomach ; its size is large and irregular, its margins are fringed and thin ; and the sur- rounding tissues are pulpy or gelatinous and transparent, having a semi-dissolved appearance, and a pale, whitish, yellowish colour, sometimes streaked with brown or black lines from the action of the acid juices on the blood remaining in the capillaries. — (b) Eroding ulcerations of the stomach, such as have been described above (§ 35 — 37.), and which are with difficulty dis- tinguished from the post mortem effects of the gastric juice, may end in perforations, having pale, thin, and soft edges, especially in children. Dr. Coste records two instances of such per- forations in the stomachs of adults, caused by the oxymur. of mercury and spirits, long and largely employed. — (c) A portion of the canal very rarely sloughs so as to involve all the coats, and to give rise to perforation when the slough is thrown off, excepting in cases of poisoning by acids, and of strangulated hernia. — (d) Ulcera- tion is the common cause of perforation, and is most frequently, in such cases, seated in the solitary or aggregated glands of Brunner and Peyer.—a. It may occur suddenly, and peri- tonitis supervene, the patient having previously appeared in good health. Such instances are re- corded by Male, Rogers, C. Smith, Cramp- ton, Travers, Laennec, Andral, and Bourienne (Journ. de Med. t. xxxvi. p. 464.), as having occurred in the stomach;' and by Neu- mann and Hufeland (Journ. der Pract. Heilk. b. ix. p. 170.), the perforation having taken place in the duodenum and jejunum. — p. Per- foration is more frequent in the course of, or during convalescence from, the gastric and enteric form of continued fever, particularly in the epidemic or rather endemic forms of it, similar to those described by M. Bretonneau under the name of Dothinenterites, and previously by Roederer and Wagler by that of mucous fevers. But it may occur in all fevers of an adynamic form, the surrounding portions of in- testine being of a dark or dirty brown, or ochry colour, softened, and often ulcerated in numerous places, or studded with minute ulcers of the ag- gregated glands. This change has been well de- scribed by Bright, Chambers and Hewett. (See Fevers — Diseased Appearances in.)—y. It is also met with after chronic complaints of the stomach or bowels, which are sometimes attended by much pain or retchings, as in the cases record- ed by J. Moore, M. Workman, Elliotson, and Hfim (Horn's Archiv. Jan. 1822.), but more frequently by little acute suffering, until after perforation, followed by peritonitis, has taken place. — 0*. It may also supervene during chronic disease of the lungs, owing either to simple ulcera- tion of the glands, or to softening of tubercular matter deposited between the gastro-intestinal coats, and consequent ulceration, as in the case re- corded by M. Legallois (see Refer.); perfora- tion from this latter cause sometimes occurring in- dependently of pulmonary disease, particularly in children.—(e) Perforation from rupture of an ulcerated, cancerous, thinned, softened, or other- wise diseased part of the canal, is most frequently observed in the stomach, and in the colon or caecum: and is sometimes favoured by stricture, thickening, &c. of the portion below it; the rupture usually arising from the over-distension of the diseased part of the canal, from external violence or pressure, and from straining at stool or vomiting. Most of the cases of rupture of the stomach and bowels recorded have been con- sequent upon some one of the changes already described, as may be seen in the cases recorded by Morgagni (Epist. liv. art. 15.), Andry (Hist, de la Soc. Roy. de Med. 1776, p. 257.), Lieutaud, Acrel (N. Schwed. Abh. b. ix. n. 3.), Portal, Richter (Chir. Biblio. b. xii. p. 403.), Sofmmerring (Notes, fyc), Sandi- fort (Observ. Anat. Path. 1. iv.), Zeviani (Mem. di Matem. e Fisica della Soc. Ital. Veron. t. v. 1790.), Hufeland (Journ. de Pr. Heilk. b. v. p. 819.), Bouillaud (Arch. G:'n. de Mid. vol i. p. 534.), Marjolin (in Ibid. vol. ii.), An- nesley, Crampton, Elliotson, Lisle, F. Davis (in the duodenum), Abercrombie, W. Cooke, and others.— (/) Ruptures of the stomach and duodenum, without, as well as with, vomitings, but without any organic change or vio- lence sufficient to account for the occurrence, have been observed by Dupuy, Lallemand,Chev- alier, and B. Brown; but,probably,softening or atrophy, or thinning of the coats also existed, although not mentioned. Perforations of the diges- tive canal are most frequent in the stomach, especially in the splenic portion. In other parts of this canal they seldom supervene, except at the bottom of ulcers ; whilst in the stomach they are more commonly produced by the other causes above enumerated. They may, however, exist simultaneously in different parts of the intestinal tube ; and may occur at every age. Cruveil- hier, Wiesemann, Gairdner and Billard have observed them in young children. I have seen them as early as two and three months in infants deprived of their nurse's milk; but they are rarely met with until after weaning. . 42. When perforation has taken place, various consequences ensue, according to its situation, and the disease and circumstances in which it has occurred. — (a) the contents of the viscus generally escape through the opening into the peritoneal cavity, and produce acute peritonitis, soon terminating fatally. But this is not a con- stant result; for the perforation may give rise to chronic peritonitis, under which the patient may continue to linger for several months. I have seen this in two instances — one in an adult, and another in a child. M. Andral notices a case in which lumbrici escaped into the peritoneal cavity through the opening, and occasioned merely an obscure lingering irritation —(b) The perforation may communicate with the cellular tissue outside of the peritoneum, as when the caecum and rectum are penetrated, and give rise to abscesses and fistulae. I have referred to cases of this description, one of which occurred in my own practice, in the article on the Cscum. —(c) In other cases, the gastro-intestinal con- tents do not pass into the abdominal cavity, owing to the circumstance of the peritoneum having, previously to its perforation, become in- flamed, so as to throw out coagulable lymph on its surface, which excites inflammatory irri- tation in that part of it directly opposite, and 548 DIGESTIVE CANAL —Morbid Secritions. thereby forms adhesions between them, and shut- the opening. When this occurs, other conse- quences ensue. — a. The adhesion may take place to some part of the peritoneum reflected over the abdomidal parietes, and the ulceration, by penetrating it, may also occasion abscess or fis- tula between the peritoneum and the walls of the abdomen. Osiander (Denkwiirdigkeiten, b. i. p. 99.) has recorded a case of this description ; and Nebel, Lieutaud, Vetter, Godot, Jac- Quinelle, and B. Gooch, instance others, in which the inflammation and matter thus formed advanced externally and opened in the left hy- pochondrium, a fistulous communication being thus established between the stomach or any other part of the digestive tube and the external surface. In this way artificial anus, or fistula in ano, commonly arises, when some part of the intestinal canal is perforated. — 1. Owing to adhesion having taken place between the surface of some viscus and the penetrated peritoneal coat of the canal, the former cither stops up the opening, preventing the escape of the gastro- intestinal contents into the abdominal cavity, or becomes itself penetrated by the ulcerative pro- cess extended thither. Meckel (Epist. ad Hal- ler. Scrip, vol. iii.) found the opening in the stomach closed by the omentum accreted over it. Zf.viani, Ch aussier (Bull.de V Ecole deM'd. de Paris, 1808, p. 41.), and Leroux (Journ. de M d. Cont. vol. xv. p. 239.), observed it covered by the spleen, into which the ulceration had par- tially penetrated. Keppelhout (Sect. Cadav. Path. L. B. 1805, p. 19.) met with a similar connection with the liver. M. Andral saw an ulcer in the ascending colon, the bottom of which was formed by the substance of the kidney ; and M. Rayer, a perforation of the duodenum stopped by the liver. Perforations of the sto- mach may be closed not only by the liver and spleen, but also by the diaphragm and transverse colon, and even may be likewise carried through either o£ them. M. Andral records cases in which the perforation passed through the sto- mach and diaphragm into the thorax, and also into the substance of the lungs, the serous sur- faces of each having previously adhered ; and a communication had thereby been established be- tween the cavity of the stomach, and either that of the pleura, or that of the bronchi. When the viscus which becomes accreted to the surface of the perforated portion of the canal has itself a cavity, then a communication generally takes place between them; thus Camper (Mem. sur le Prix, Src t. v. n. 9.) met with an opening into the bladder. Indeed, communications thus formed with either the bladder, uterus, or vagina, are not very rare. A case occurred to M. Chomel (M. Andral's Anat. Path. vol. ii. p. 136.), in which the duodenum communicated with the colon, through the gall-bladder, which adhered to both ; and cases are not very un- common, in which perforations and accretions of the serous surfaces of several parts of the digestive canal take place, and openings are thereby directly formed between them. I have seen communications thus existing in the same case between opposite parts of the small intes- tines in two places, and of the small and large intestines in three places. In another instance there existed no less than four or five such com- munications, each of which was of course a double perforation. These changes have been observed by me in four cases in children; and in all, the perforations were associated with chronic peritonitis. Dr. G. Gregory (Trans. of Med'.-Chirurg. Soc. vol. xi. p. 258.), has re- corded a similar lesion; and an instance, in which it occurred in an aged person, is given in the third volume of the Bulletins of the Faculty of Medi- cine of Paris. Dr. Abercrombie found an ul- cerated passage existing between the stomach and colon, faeculent vomiting having preceded death; Mr. A. Bellot detected several per- forations, forming openings between the small and large intestines, and into the abdominal pa- rietes of an adult female; and M. C. Broussais observed carcinomatous ulceration and perforation of the stomach, opening into the vena porta. 43. In all these, excepting the second perfora- tion, by which a communication is established be- tween jontiguous portions of the canal, as in the cases now alluded to, the opening takes place from within outwards. But the perforation may be produced in an opposite direction, as where abscesses of the liver burst into the stomach or colon, M. Cayol (Journ. de M'd. by Corvis- art, fyc. vol. xiv.) mentions a case in which an abscess in the kidney burst into the ascending colon. Abscesses, perforating, and opening into, the rectum, that had formed, in one case be- tween it and the uterus, and in another between it and the sacrum, during convalescence from fe- ver, have occurred in the practice of the author. 44. iii. Morbid Secretions in the Diges- tive Tube.—These may form on the free surface of villous coat, or in the substance of the parietes of the canal.—A. The secretions and fluids found on the internal surface of the villous coat are—1st, the natural secretions altered from the healthy state; and, 2d, those which are altogether adventitious and foreign to this situation.—(a) The mucous secretion and the aqueous and gaseous exhalations may be increased in quantity; and otherwise modified.—a. The mucus covering the villous surface is often greatly increased in quantity, and modified in consistency, either throughout the tube, or in portions of it only ; this membrane itself being commonly of a bright red, and more or less injected; or of its natural colour, or sometimes even paler than usual.—p. The aqueous exhala- tion is also occasionally increased on the villous coat, and the vessels more or less congested, par- ticularly the veins. The existence of increased aqueous exhalation, connected most probably with determination of the circulating fluid, is evidently the chief pathological state in cholera and serous diarrhoea. But vascular congestion is not always found upon dissection in those cases, especially if the person have died of some other disease, of which serous diarrhcea was a con- tingent symptom. In these the parietes of the intestines are generally attenuated and pale, and contain more or less of a serous, yellowish, or colourless fluid. — ). The gaseous fluids, of which the digestive canal usually contains more or less in health, are often greatly increased, and are sometimes a very important symp- tom, although not constantly or generally con- nected with any one pathological state. In- creased exhalation of the intestinal gases is, DIGESTIVE CANAL—Morbid Secretions in. 549 however, a very frequent, although not a con- stant, result of inflammatory irritation of the villous membrane, or of disease of Peyer's glands ; but it may also proceed from extreme debility, manifested especially iu the organic nervous system, and by the bloodless state of the digestive canal found after death. Hysteria, hypochondriasis, asthma, flatulent and lead colic, rabidity, and other affections, are characterised by great accumulations of air in the intestines, without any sign of vascular irritation of the villous surface. These gaseous collections are generally greatest in the large intestines; but they also take place in the stomach and small intes- tines, particularly in the latter, as observed in the last stages of typhoid fevers, and of various other acute diseases. The meteorismus of fever has been imputed by Broussais to disease, especially ulceration of the intestines ; but, although the connection is frequent, it is by no means general, and, even when observed, both pathological states are merely associated effects of the same anterior change, viz. diminished vital power, expressed particularly in the organic nervous system and viscera influenced by it. The formation of air in the digestive canal has been chiefly attributed, in the article on Colic, to exhalation from the villous surface. It may also arise partly from the chemical reaction of the diversified and he- terogeneous substances taken into the stomach, as they are acted upon by the secretions and are propelled along the canal, and a portion is com- monly swallowed with the ingesta. 45. (6) The fluids and secretions foreign to the digestive canal in health, but which are some- times found in it, are, blood, pus, coagulable lymph, melanotic matter, tubercular matter, con- crete or fluid fatty matter, a thick albuminous substance, calculous concretions, and worms. — a. Blood is occasionally found in the stomach and thtestines, both in a fluid and coagulated state, and in very variable quantity. The causes of its effusion on the free surface of the villous coat are — 1st, Atony of the extreme vessels, and diminished vital cohesion of the coat ; — 2d, A mechanical obstacle to the return of the blood, particularly in the vena porta ; — 3d, Inflamma- tion or irritation of the villous membrane in various states of intensity and morbid association, supervening either spontaneously, or caused by irritating ingesta; — 4th, A morbid or dissolved state of the blood itself, most frequently, how- ever, associated with the 1st state, as in scurvy, the black vomit of yellow fever, and purpura hsemorrhagica ; —5th, The erosion of the coats of a blood-vessel in the seat of an ulcer ;—6th, Disease of the coats of a blood-vessel, indepen- dently of any lesion of the villous coat; — and 7th, From having been swallowed, as in cases of excessive haemoptysis, haemorrhage from the fauces, &c. When the sanguineous effusion proceeds from the third source, it may be either very slight, the mucus covering the villous sur- face being merely tinged with it, or very con- siderable, according to the various concomitant circumstances under which it may take place. It* fifth and sixth sources are the most rare, but not so rare as M. Andkal supposes, the sixth being entirely overlooked by him. M. Prost, Dr. Abercrombie, and others, have detailed instances of the former ; and a case of the latter, 46 from atheromatous deposit in the coats of an arterial vessel disposing it to rupture, very recently occurred in my own practice. (See Hemorr- hage—from the Digestive Canal.) 46. p. Puriform matter is but rarely met with on the villous surface, instead of the mucus usually secreted by it, in any appreciable quan- tity. It is much more commonly found in the follicles, either in an inflamed state of this coat, or independently of any marked injection of its vessels. When the follicles contain this fluid, they generally present the appearances already de- scribed (§ 22. c, 36. c), especially the conoidal and pustular state, the puriform matter escaping on incising them.—y. Dr. Monro describes a brown fluid like cocoa, which he has seen in some in- stances voided in large quantity during life from the stomach. In a fatal case, this viscus was very large, and half filled with this fluid, its coats and adjoining viscera being sound. — 3. Coagulable lymph, in various grades of density, and in the form of false membranes, is also sometimes found on the gastro-intestinal villous surface; but not so often as in the mouth, pharynx, and oesophagus. I" have observed it most frequently in the form of whitish flocculent or thin membranous-like patches and shreds, covering the inflamed or partially injected sur- face, in fatal cases of scarlet fever, with gastro- intestinal symptoms. In sub-acute inflammatory affections of the digestive organs, either with or without diarrhoea or dysentery, as in the cases described by Baillie,Powell,Good, Annes- ley, Lelut, Billard, &c.,the false membrane is occasionally so complete as to form a tube of various dimensions, which, when evacuated with the stools, has been mistaken for a sphacelated portion of intestine, or for its mucous coat. Dr. God man found it covering the whole villous sur- face of the stomach; and .Mr. IIowship remark- ed a similar production iu a child that had acci- dentally swallowed boiling wnter. M. Andral thinks that it may sometimes proceed from a morbid secretion of the mucous follicles; but, as in the other situations in which it is seen, it evi- dently arises from inflammatory action of the villous or mucous coat itself, the exhalant vessels of which, in the inflamed state, throw out co- agulable lymph instead of their usual watery or serous exhalation ; these vessels also sometimes secreting puriform matter, in a modified form of disease. — t. The gastro-intestinal mucous coat sometimes exudes a black matter, the melanosis of modern writers. This substance exists either in a fluid form, on the free surface of the mem- brane, or combined with its tissue, or in both forms in the same or different parts of the canal. When merely deposited on the free surface of this coat, it can generally be washed off; the matter composing it staining linen. But when it is infiltrated or combined with this tunic, it cannot be removed by ablution, and it does not stain linen. It is most apparent at the bottom of the lacunae in the duodenum, or in the sum- mits of the villi, or in the margins of the orifices of Peyer's glands, or in the bottoms of small ulcers.—J" Tuberculous matter is sometimes found in the follicles, the intestines being studded with a number of small white bodies, seldom exceed- ing the bulk of a pea. The substance they contain is concrete, whitish, and friable. M. 550 DIGESTIVE CANAL—Complicated Productions in. Andral remarks that these tumours are merely the follicles altered in their nutrition and secre- tion ; the affection being a genuine acne of the mucous membrane. — >,. Fatty matter is very rarely met with in the intestinal canal; but sever- al cases are recorded in which it has been passed in a fluid and concrete state during the advanced stage of chronic diseases.—fl. A thick albumin- ous matter is generally found covering the villous surface of the small and large intestines of those who die early in the Pestilential Cholera. (See art. Pestilence.) Of Calculous Concretions and Worms in the digestive canal, a detailed account is given in their respective articles. 47. B. Morbid productions in the tissues com- posing the parietes of the digestive canal.—a. Blood is sometimes effused in the sub-mucous cellular tissue to an extent varying from a line to some inches, often without any change in the mucous membrane, and generally from the same causes as have produced its effusion within the canal (§ 45.)—6. Serous infiltration, or oedema, of the cellular tissue connecting the different tunics and muscular fasciculi with each other, is sometimes observed in various degrees, the thick- ness of the parietes being thereby proportionately increased. The fluid occasionally raises up the villous surface in the form of blisters or small vesicles. (Edema is most frequent in the large intestines, the villous membrane being remark- ably pale, or more or less injected and variously coloured, or softer than natural, or even more consistent, or ulcerated, either independently of disease of its follicles, or in the seat of Peyer's glands, and with enlargement of them. The cellular tissue itself, the seat of serous infiltra- tion, may be unaltered or softened, or hypertro- phied, thickened, and indurated. In the latter case, it is, in some places, dry, and grates under the scalpel, without yielding any fluid ; and in others, there are considerable deposits of serum, or of a gelatinous fluid of various consistency, constituting one of the more frequent states of what is usually called scirrhus, as met with in the pylorus or cardia of the stomach, or in the rectum. CEdema, in the different forms now enumerated, is often the chief lesion observed after chronic diarrhcea and dysentery, and pro- longed affections of the stomach. The exhala- tion of serum may also occur within serous en- velopes or cysts, developed between the villous and muscular coats, and varying from the size of a pea to that of an egg.—c. Gaseous exhalations may take place between the coats of the diges- tive tube, soon after death, from incipient decom- j position; but a case observed by M. J. Cloquet (Bullet, de la Faculte de Med. vol. vii. p. 267.) shows that it may also supervene during life.— d. The secretion of fat has been observed in one instance by M. Andral in the sub-mucous cellular tissue, the coats of the small intestine, in which it formed a small tumour, being quite sound.—e. Purulent matter is seldom found in the substance of the gastro-intestinal tissues, and then only in small quantity in the sub-mucous and connecting cellular substance—forming either one or more collections, which are generally encysted, but also infiltrated in this tissue. These small abscesses should not be confounded with the pustular-like tumours, containing pus, form- ed by inflamed follicles. They do not appear to give rise to any peculiar symptom.—/. Tuber. cular matter is secreted more frequently than pus in the gastro-intestinal parietes, particularly in the lower part of the small intestine, and gen- erally in the cellular tissue connecting the coats. It forms small whitish tumours, owing to the colour and form of the deposition being percep- tible through the elevated villous or peritoneal membrane, varying from the size of a millet seed to that of a pea. They may be very few or numerous—usually the latter in persons who have had tubercles in the lungs, particularly at the margins and bottoms of ulcers. They may exist long without giving rise to any symptom referrible to the digestive organs, until the mu- cous membrane becomes affected, when diar- rhoea—generally chronic and intermittent—is the usual result. The membrane over and around these tubercles may be unaltered, or injected and inflamed, variously coloured, softened, ulcerated, &c. The softening and breaking down of the tubercular matter, and the attendant ulceration, may also terminate in perforation, as in the case published by M. Legali.ois.—g. Melanoid matter is occasionally deposited in the cellular tissue connecting the coats, either in a diffused or disseminated state, or in isolated spots, forming small projecting tumours. — h. Osseous matter is very rarely deposited in any part of the gastro- intestinal canal. De Ha en (Rat. Med. vol. iv. cap. i.), however, met with it in the stomach; and Short (Edin. Med. Essays, vol. iv. p. 353.), in the colon and rectum. 48. iv. ComplicatedProductions gener- ally THE ADVANCED STAGES OF MoRBID Nutrition and Secretion conjoined.— The morbid formations now to be mentioned, are chiefly the advanced stages of two or more of the morbid changes already described; and, as might be inferred a priori, so nearly approximate to each other in their external characters, as well as in their anatomical and chemical elements, as often to render it a matter of difficulty to distin- guish between them, unless in an arbitrary man- ner. From this gradual approximation of the ap- pearances of organic lesions to one another has arisen the difficulty of describing and arranging them; and from attempts at both having been made without being aware of this circumstance, or adverting to it sufficiently, or from endeavouring to establish, in respect of morbid changes, that which has been successfully performed in regard of the living productions of nature, and of which the former does not, but the latter does admit,— from describing as unvarying species what ia merely constantly changing varieties,—has arisen much confusion and misconception. 49. A. Local or partial hypertrophy of the villous membrane, forming the excrescences al- ready noticed (§ 27.), seems to be an early stage of several changes, which have been variously denominated, according to the appearances they have presented, and which have evidently arisen from alterations of their nutrition, and interstitial secretion, probably occasioned, as well us modified, ! by local irritation, constitutional vice, tempera- ment, diathesis, age, and vital endowment.—(a) The simplest of these productions seem to be the polypous or fleshy mass, which may assume either a pyriform, oval, or spheroidal form; with a broad or narrow base, and an opaque, dark red or pur- DIGESTIVE CANAL —Complicated Productions in. 551 plish colour, and various grades of consistency, and of vascularity chiefly as respects its venous circulation. It has been found in the stomach by Morgagni, Monro, Granville, and others; and in the intestines by Rhodius,Portal,Mon- ro, &c; and has been seen as large as the closed hand. After repeated irritation, it may either throw out much blond, or may experience a sloughing or destructive form of ulceration. — (b) Other modifications of polypous tumours present a tabulated, irregular, or fissured surface, with a more decidedly fungous appearance and spongy structure than the foregoing, particularly in the old and debilitated. They are commonly dark- coloured, abound more with varicose-like veins, are less homogeneous internally, are more cellu- lar, spongy, and vascular, and contain a dark serous or sanious fluid in their areolae or minute cavities. They also bleed more frequently and profusely than the preceding, and discharge a fcetid and sanious matter ; and, when they ul- cerate, assume the form of a soft fungous mass. They have been mistaken for fungus hamatodes, but, although they very closely resemble the haematoid form of it, they differ from it in oc- curring primarily in the digestive canal, and not simultaneously in other parts, in being more spongy than it, and in containing little or no albuminous or brain-like substance. — (c) A third modification of these polypous produc- tions has been described by Dr. Monro under the name of milt-like tumour. It approaches in appearance that variety of fungus hama- todes which has been denominated encephaloid, from its brain-like structure. The milt-like form- ation resembles in colour and consistence the milt of some fishes, extends to a large size, and is very slow in its growth. It is exter- nally of a pale red colour, with an irregular surface, emits an offensive foetor, and is covered by a fine membrane, in which a number of in- jected vessels are ramified. It has a homoge- neous structure, consisting chiefly of a whitish albuminous secretion deposited in the texture, or under the epithelium, of the villous membrane; and is imperfectly organized. It Is partly mis- cible with water, and is somewhat hardened by spirits ; the surface to which it is attached, and the adjoining parts, being discoloured, vascular, abounding with large engorged veins, and, when it is removed, presenting a villous, honey-comb appearance, besmeared with drops of blood from the torn vessels. The neighbouring lym- phatic glands generally participate in the disease, and are filled with a similar matter. This struc- ture differs from the true fungus hamatodes in j being found only on the digestive mucous sur- | faces ; the latter, in every situation. It is also not so firm and elastic, nor so dark-coloured and j purplish, nor of so unequal a consistence in different parts, as that disease. Moreover, it is not liable to fungous ulceration, as the latter is ; and while it occurs only in advanced life, the \ true haematoid or encephaloid disease is most com- mon in early and middle age. It is met with most frequently in the stomach, and severiil cases of it are detailed in Dr. Monro's instructive work. 50. B. The various states in which simple scirrhus or scirrho-carcinoma presents itself in j the digestive canal have been here ascribed chiefly to hypertrophy of the sub-villous cellular ' tissue ; and to the modifications of nutrition and secretion superinduced in it by long continued irritation, morbid diathesis, advancing age, and depressed vital power. In the simple states of scirrhus, the hypertrophy of the tissues to which it has been chiefly attributed (§ 30.) may be distinctly traced , the thickening and induration of the sub-villous cellular tissue amounting in many instances to a fibro-cartilaginous change. But in further advanced stages, or in states of the disease which are different from the com- mencement, a more complev. lesion evidently obtains; two or more, and ultimately even all, the anatomical elements of the part being involved in this change. Scirrho-cancer is most frequent iu the pyloric extremity of the stomach, the cardia, the rectum, the sigmoid flexure of the colon; but it may occur in other parts of the stomach and small or large bowe!s; and has been described by Morgagni, Baillie, Pin el, Howship, Monro, Chardel, Armstrong, Paletta, Louis, Bayle, R. Prus, Cruveil- hier, and Craigie. It appears commonly to commence in the sub-villous tissue; the mucous fol- licles, the villous tissue itself, the muscular coat, the blood-vessels, the lymphatics, the nerves, and lastly the serous coat, evincing sensible evidence of change. But, although the former of these are the first to manifest altered structure, there is every reason to infer that the morbid condition orignates iu the organic nerves of the part, their functions only being at first affected; and that lesions of circulation, secretion, and nutrition, more or less gradually result, and ultimately the organic changes which are found implicating the above anatomical elements.—(a) 1 he scirrhous and simpler state of this change consists of a greyish white structure, sometimes inclining to yellow, interposed between the internal surface and the serous coat of the part, frequently with lighter coloured and denser fibres — in some cases approaching to the fibro-cartilaginous tex- ture — running through it, and generally in a transverse direction to the axis of the canal. This change may be confined to the connecting cellular tissue (§ 30.), or be coeval with a simi- lar change in, or progressively implicate, the mucous follicles, and the villous or muscular coats. Along with the circumscribed thickening and induration of the part, a contraction of its canal generally takes place; the villous coat or the mucous follicles of the more prominent places become ulcerated; and, either consecutively or simultaneously, the interior of the morbid struc- ture is partially softened and disorganized. Sub- sequently to this, a phagedenic, and, in some cases, a fungous form of ulceration rapidly pro- ceeds; death, however, frequently anticipates this change. In rare instances, this structure is much more soft, lardaceous or pusty, and indented by erosions; and is chiefly met with in the rectum. I have, however, seen it once in the pylorus.— (b) In another variety, the scirrho-cancerous structure consists of circumscribed and irregular or nodulated masses; and, in the opinion of Monro and Craigie, commences in the mucous follicles. Its internal structure varies, but gene- rally consists of a hard fibrous-like structure or bands traversing a soft or pulpy substance, fre- quently containing a gelatinous or ichorous fluid in minute cavities. (See Cancer.) At a more 052 DIGESTIVE CANAL— Chanoes advanced stage it becomes softer, often in sepa- rate parts, and at last ulcerates, leaving cavities with hardened, scirrhous, and ulcerating sides. It is most frequently found obstructing the ori- fices of the stomach. — yc Scinho-cuncer of the digestive canal is not always limited, but some- times extends to the adjoining parts; ahd it may attack distinct portions, or even other viscera, either simultaneously or consecutively. Gene- rally the peritoneal coat is the last to be affected, and, when implicated, it resembles coarse parch- ment. Ihe rugae of the internal' surface are generally thickened and indurated, or eroded and ulcerated in the centre, or studded with small hard tubercles. There are often fungous growths in the advanced stages, proceeding from the ulcerated surface, which has ragged, unequal, and retorted edges; the disease being then in an open or carcinomatous state. In some instances the adhesion precedes the ulcerative process; and thus life continues, though all the coats are destroyed, and the malady is extended to the adjoining parts. When adhesion hns not taken place, the ulceration communicates with the cavity of the peritoneum. If the malady be situ- ated so as to interrupt the passage through the canal, the parts above it generally becomes very much enlarged, at first thickened, but afterwards thinned, and ultimately either ulcerated, per- forated, or ruptured. The thickness and hard- ness of the diseased part vary much. When it is seated in the cardia or the pylorus, it may extend to the diaphragm or duodenum respect- ively, and so on as to other parts. The lymphatic glands in the vicinity are usually enlarged and scirrhous. The progress of the malady is gene- rally very slow; but in other cases it is more rapid. 51. C. Medullary Sarcoma — Hamatoid, or encephaloid disease — may originate in any of the elementary tissues of the digestive canal. It also presents modifications, according as the encepha- loid, or medullary, or the vascular structure pre- dominates. But it differs from the fungous and scirrho-cancerous maladies, in its more obvious connection from the commencement in constitu- tional vice, in the greater rapidity of its progress, in its belonging to early age, and in its simulta- neous or consecutive occurrence in different and unconnected parts. Its colour varies remarkably: it being generally much lighter when the medul- lary or albuminous substance is greatest, and passing through every shade to a violet or purple, as it becomes more vascular, and consists more of convoluted and injected capillaries; and varicose- like and congested veins. It generally consists at first of a soft elastic and distinct tumour, with- out fluctuation, but occasionally of unequal firm- ness in different parts. In its progress it bursts, and a soft dark or purplish fungus, which bleeds profusely, rises from its centre, and rapidly in- creases. When divided, separate portions of it exhibit different colours and consistence, — some being as soft as brain, others as hard as the boiled white of egg, and others like cartilage, — and cavities of various sizes and forms, containing a bloody fluid. It experiences a fungous ulcer- ation, and, as it extends, implicates or converts into its own form the tissues surrounding it. It occurs more frequently in the stomach than in others parts of the canal; and when it obstructs the orifices of this viscus, occasions the further changes of Capacity and Situation. noticed with reference to the preceding lesion. (See HyEMATO-ENCEPHALOID DlSEASK.) 52.v.ChangesofCapacityandSituatioi». — A. Increased capacity of the alimentary cuna] is usually partial only — in one of its compart- ments; and is often associated with, and, indeed, occasioned by, narrowing or constriction of a part immediately below it. General increase of capa- city has, however, been observed in some cases of'bulimia. The stomach and large bowels are most frequently thus altered; either of which may become so much enlarged as to occupy the greater part of the abdomen. Cases of this description have been observed by Plater, Morgagm, Hasenoehrl, Hamberger, Frank, An- derson, Stoerck, Sandifort, myself, and others; and are usually attended by thickening, in- duration and constriction, or scirrho-carcinoma of the pylorus, when the stomach is dilated; and of the rectum, when the colon is thus changed. M. Andral found the duodenum as large as the stomach in a case where the commencement of the ilium was contracted. When a portion of the canal becomes constricted or obliterated, either from simple thickening, induration and ulceration, or from scirrhus or carcinomatous disease, the part above may be not only dilated and sacculated, but also attenuated or even ulcerated, or it may ultimately burst from the consequent fteculent and flatulent distension. Cases of this description have been recorded by Girdlestone, Burrell, Anneslfy, and others. Instances of great dila- tation of a part of the canal, without contraction of a part below it, are rare. M. Andral, how- ever, found the stomach excessively dilated in two cases, without any obstruction of the pylorus. 53. B. Diminished capacity also is generally a partial change, and seldom observed throughout the canal, excepting in a slight degree, after long fasting or death from starvation, or after an ex- cessive or prolonged use of acids and astringents. The stomach has been found as narrow as an in- testine after poisoning by acids, and sometimes after irritating substances; and the intestines con- tracted throughout from the same cause, and the protracted use of acids and powerful astringents. In cases of artificial anus, the portions of intestine below it, no longer receiving the matters trans- mitted along the canal, contract remarkably, their cavity being filled with mucus. Obliteration of the cavity of some part of the digestive tube may take place either partially orcompletely—1st,from intrinsic causes; and, 2d, from extrinsic causes, or changes external to it, but which alter or de- stroy the permeability of its canal. The intrinsic causes are — (a) hypertrophy, with induration of one or more of the tissues forming its parietes; (6) excrescences or polypous growth on its inter- nal surface; (c) concretions, either calculous or faecal, or a ball of worms ; (d) constriction of the muscular coat in a circumscribed part. In this last form of constriction, which is not infre- quently observed in fatal cases of dysentery, and of which several delineations are given by Mr. Annesle v in the work referred to, the adjoining portions of intestine are commonly distended by air; the internal surface of the constricted part being generally either injected, or ulcerated, or otherwise altered in structure. The contraction observed about the middle of the stomach, uncon- nected with any change of the tissues, by Wep- DIGESTIVE CANAL — Changes or Capacity and Situation. 553 rr.R, Morgagni,Df.Haen,E.Home,Monro, Nacquart, and others, has been ascribed to spasmodic constriction; whilst some conceive that it exists very generally during congestion. Soem- me rring imputes it to the pressure of the stays, as it has been noticed chiefly in females. The four specimens figured by Meckel all occurred in this sex (Tab. Anat. Path. fasc. iii. tab. 20.). The most common intrinsic cause of permanent contraction or diminished capacity of a considerable part of the digestive canal is that first assigned,— hypertrophy, with induration, of some one or more of its coats, either with or without ulceration. Nu- merous cases illustrating this are on record. Dr. Drak e found the stomach diminished to one third of its capacity, its coats being thickened threefold throughout; and instances of thickening, indura- tion, ulceration, and contraction of large tracts of the intestinal canal—most frequently of the large bowels—have been recorded by Hill, Green- hoav,Burrell,Holmes,Carter,Bouilla- ud, Howship, Monro, and many of the writers referred to. Besides these, other instances of the va- rious forms of intrinsic constriction, or contraction from organic change, occurring in the stomach, and in the small as well as the large intestines, are adduced by Bartholin, Bonet, Wal- ther, Haller, Portal, MichaSlis, Mol- linelli, Loesecke, Mollison, and several others, in places referred to in the Bibliography. 54. C. intimately connected with muscular or spasmodic constriction of some part of the canal is the occurrence of introsusception; the con- tracted portion passing within the adjoining dilated part. A large proportion of introsusceptions takes place at the moment of dissolution, particularly in children, as justly remarked by Camper, Monro, J. Davies, and others ; at least, no symptom referrible to it had occurred during life. The usual results of this change both of capacity and position are strangulation of the re- tained portion of intestine, and obstruction or ob- literation of the canal; with the symptoms of Colic and Ileus (§ 39, 40.), and internal strangulation. In all introsusceptions, the villous coat is inner- most; next, the two serous surfaces are in contact; and more externally still, the two villous surfaces are also in contact. This arrangement, as M. Dance (In Repert. d'Anat. et Path. 8fc. t. i. p. 441.) has shown, should be recollected, as it ex- plains how, in consequence of the constriction and inflammation of the introsuscepted portion, its serous surfaces, which are in close contact, adhere; and, owing to its consequent strangulation and sphacelation, the whole of it is sometimes detached and passed by stool, without any of the intestinal contents escaping into the peritoneum. Instances of this kind have occurred, and several are recorded in the works referred to. Introsus- ceptions are most frequent in the small intestines, several sometimes occurring in the same case. They may also take place in this situation to a small extent without any bad effect. A large portion — even the greater part of the small in- testines— is in some instances invaginated in the caecum and colon; and, in rarer instances, the caecum itself, either with or without portions of the ilium and colon, may be introsuscepted into the sigmoid flexure of the last (Hevinus, Mon- ro, Andral, Dance, and myself). 55. The extent to which the intestinal canal may be thus invaginated is extremely various — from a few lines to many feet. The introsus- cepted portion may even protrude more or less through the anus. Instances of this kind are recorded by the writers now mentioned, and by many others. When the invaginated part sphacelates, sloughs are thrown off, leaving perforations, through which the intestinal con- tents may pass into the peritoneum. But when, owing to the circumstance just explained, this part is separated, perfect adhesion of the parietes of the intestine at the point of separation taking place, the canal suffers no interruption of its con- tinuity. In this case, the invaginated part is passed by stool. Hevinus met with an instance in which twenty-three inches of the colon, and another in which twenty-eight inches of the ilium, were evacuated. Cruveilhier and Andral saw twenty and thirty inches of small intestine, with a portion of mesentery, thus passed. Cases in which an opportunity occurred of examining the intes- tinal canal at a remote period from the separation of the invaginated part, are recorded by Hevinus and Dumeril. In that by M. Dumeril, six inches of the jejunum and ilium had been de- tached. Upon examination after death, the two extremities of the intestines were perfectly united, their edges having been bevelled and exact! v fitted to each other. They had contracted adhesions to the peritoneum at their junction, but the canal was not sensibly diminished even at the cicatrix. 56. D. The extrinsic causes of obliteration or strangulation of the digestive canal are numerous, and have been referred by M. Andral to an irregular disposition, either of the peritoneum or of the intestinal canal itself.—1st, Those depend- ing upon the peritoneum are — a. Perforation of the mesentery; — p. Perforation of the omen- tum;—/. Strips of the omentum adhering to the abdominal parietes, and entangled a coil of in- testine;—A. Fraena extending like arches from a portion of intestine to some other organ, as from the uterus or ligamenta lata of the rectum (Es- quirol) —or from a portion of intestine to the abdominal parietes — or from the omentum to a part of the abdomen—or from one of the abdo- minal viscera to another; — f. The mesentery or omentum, involving a coil of intestine, when folded or rolled together. — 2d. The causes of strangulation seated in the tube itself are—u. The compression of one portion of intestine by another, as a portion of the transverse colon situated between the vertebral column 3nd the duodenum (M. Gendrin , in Jirch. de Med. b. viii. p. 494.);—p. The escape of an introsuscepted portion of intes- tine through a perforation or rupture in the con- taining part, the introsuscepted portion being strangulated by the margin of the perforation. (M. M. Solon, in Bullet, de la Soc. Mid. d'Emu- lation, 1822.);—•/. Twisting of the appendix of the caecum around a portion of the ilium, com- monly owing to the unusual length of this part;— 9. Adhesions of the extremity of the appendix, so as to form an arch or ring, in which a portion of intestine may become entangled; — h. The twisting of a diverticulum around either the part from which it is produced, or a coil of intestine; —". Adhesions of the extremity of a diverticulum, which may compress a portion of intestine over which it passes, or that portion to which it is at- tached. All these causes may, however, exist 554 DIGESTIVE CANAL—Congenital Lesions of Dimension and Situation. without giving rise to internal strangulation. But they more frequently produce it either slowly or suddenly. In the former instance, symptoms in- dicating a greater or less obstacle to the passage of the intestinal contents are generally complained of for weeks, months, or even years, before the signs of strangulation appear. In the latter case, no premonitory symptoms are observed. 57. E. The situation of parts of the digestive canal may be changed in several ways, which are referrible to two principal classes:—1st, Alterations of situation in respect of different parts of the tube, and of the related viscera,—or internal dis- placements;—2d. Protrusions through some part of the abdominal parietes,—or external displace- ments, (a) Internal displacements arise from—u. obstruction; p. alterations of its calibre; and, y. the impulsion or dragging of adjoining parts. The stomach is not infrequently partially displaced from some one of these causes, especially its py- loric extremity, and generally in consequence of scirrhous thickening and induration, or tumours developed in it or its vicinity. I have seen the scirrhous pylorus form a tumour below the um- bilicus, — a circumstance which might have led to an incorrect diagnosis, if it had not been known occasionally to occur. This viscus may also be dis- placed by the dragging of the omentum in a large hernia, the pyloric extremity descending equally- low from this cause, as in a case recorded by Dr R. Lowis. The situation of the small intestines, cacum and colon, is also frequently changed from the causes now stated. Alterations of this des- cription in the two latter of these have been notic- ed in their respective articles. The second or ex- ternal class of displacements belong to the province of the surgeon, the medical relations of the subject falling more appropriately under the articles Dys- pnoea, in which diaphragmatic hernia is noticed, and Peritoneum, where the diseases of the serous coat of the digestive tube are considered. 5S. vi. Congenital Lesions of Dimension andSithation .—The gastro-intestinal canal has never been found wholly wanting, even in mon- strous productions. Of the different parts which constitute it, that proved to be the first formed is never deficient. This is the extension of the ves- icula umbilicalis into the intestinal canal, which, however, may be arrested in its formation before oue or other extremity of the tube has been pro- duced, thereby occasioning deficiency of a portion of either, or the imperforation of their outlets. With the various congenital faults of configuration, dimension, and situation, it is unnecessary to oc- cupy my limits. A few only of the most impor- tant may be noticed. 59. A. The dimensions of the digestive canal may be lessened or increased, either throughout, or in parts only.—(a) The stomach has been found so small as not to exceed the diameter of the small intestine. The convolutions of the small intestines have been observed less numerous or nearly wanting, and the length of the canal from the cardiac orifice to the anus hardly equalling that of the individual. The cacum has sometimes been so small as not to form a cul-de-sac, or it has been, as well as the appendix, altogether defi- cient, the ilium opening directly into the colon.— (6) Increased dimensions of some part of the di- gestive canal are more common than the preced- ing. In infants and children, the stomach has been found of a remarkable size; and in some, the duodenum has been as large as the stomach. Ihe caecum, or its appendix, has also been very large. I3rugno.ni anil Meckel (Tab. Anat. Pathol. fasc. iii. p. 23.) have adduced instances of two colons springing from a single caecum, and reunit- ing at the rectum, in the case of the former; but terminating in cul-de-sacs, floating freely in the abdomen, in that of the latter. One part of the canal has been found greatly increased in size, whilst the other is diminished. M. Cabrol found the stomach of a person so large as to fill the greater part of the abdominal cavity, and the small and great intestines together little longer than three feet. — (c) Appendices or diverticula are sometimes attached, like the fingers of a glove, to the side of the canal. M. Andral states them to be most frequent on the jejunum and ilium, and.MECKEL on the lowest third of the ilium; but they have been found on the duodenum and on the rectum (Morgagni).—Their cavities are continuous with that of the intestine, and they ter- minate in a cul-de-sac, which either floats loosely in the peritoneal cavity, or adheres to some ad- joining part. Their length varies from a few lines to three or four inches. They may either fall short of, equal, or surpass, the diameter of the intestine whence they spring; and they form every angle with it. They vary in number from one, which is most common, to five or six in the same portion of intestine. Their terminations are rounded or pointed, and they sometimes present a series of dilatations and contractions. Meckel saw one inserted into the navel, forming a kind of umbilico-intestinal canal. From this and other circumstances — particularly their being com- monly found single, and on the lowest third of the ilium — he infers that true diverticula are the re- mains of the original intestine formed by the ve- sicula umbilicalis; and contends that, when they occur in any other situation, or when more than one exists iu the same case, they are false, and consist merely of hernia of the villous through the muscular coat, or of some other change (Ueber die Divertikel, in Reil's Archiv. fyc. b. ix. h. 3.,et Tab. Anat. Path. fasc. iii. pi. 21.) They seem to dispose the adjoining portion of intestine to or- ganic change, as well as to alterations of capacity, as in the cases recorded by Dr. Fr a n c i s and others. 60. B. The situation of the digestive tube, or of parts of it, is variously changed, either by ori- ginal conformation, or by accident or disease. The congenital abnormal positions of the viscera are so numerous, and of so little importance in a practical point of view, that I shall not touch on them. The reader will find them described in the works of Meckel and Andral referred to in this article. Imperforations of the canal come not within the scope of the work. 61. As the same alterations of structure occur in all the parts constituting the digestive canal, | although in different degrees of frequency, I have described them in a connected manner, in order to prevent the repetition that could not be avoided if they had been comprised in the articles on the Intestines, Stomach, &c. But in these, and some other articles, I have detailed the symptoms of those alterations, and the treatment they re- quire, because the same lesions, seated in different parts of the canal, are attended by different phe- nomena, and claim modified means of cure ; DIGESTIVE CANAL — Bibliography and References to its Lesions. 555 reference being made to the changes here de- scribed. Therefore, the diseases of the diges- tive canal should be also studied in the following articles, which contain most of what is known respecting them :—C^cum, Colic and Ileus, Colon, Concretions, Constipation, Diar- rhol a.Duodenum, Dysentery, Fauces, Fe- vers, Indigestion, Intestines, (Esopha- gus, Peritoneum, Pharynx, Rectum, Stomach, Worms, &c. Bibi.ioo. and Refer. — i. General Treatises.— Waldschmidt, De Ventric. et Intest. Morbis. Marb. 1684 — Kraus, De Intest. eorumque Morbis. Jenae, 16 4,—Glis- son, De Ventric. et Intestinis, tr. ii.—J. M. Hoffmann, Dis- quisitio Corp. Hum. A at. Pathol, kc. 4to. Altd. 1713__ Bauer, in Holler's Biblioth. Med. Pract. iii. p. 461.—Peyer, Exercitat. de Gland. Intest. par. ii. p. 80.—Adolphi, De Tunica Intest. Villosa foco Morb. &c. Jens, 1721.; et De Colo Intest. Mult. Morb. Nido, &c. Leips. 1718.—Hal- ler, Morbi aliqui Ventric. in C dav. Ohservali. Goet. 1749.— Lieutaud, Hist. Anat. Med. 1. i. observ., 400., et passim.—Stunzer, De Morb. Intest. &.c. Tub. 1767.— E. Sandiftrt, Observ. Anat. Path. 4 vols. 4to.. L. Ii. 1777, 8vo.—C. F. Lurlwig, Prima; Lines Anat. Pathol. 8vo. Leips. 1785.—Vicq d' Azyr, Anat. Path, in Encvcl. Mi- thodique. 4to. Paris, 1789. — M. Baillie. The Morb. Anat. of the Hum. Body, 5th ed. Lond. 1818. — A. R. Velter, Aphorisuien aus der Pathol. Anat. &c. Wien, 1803.—Prost, M. d. Eclairee par 1'Ohse vat. et 1'Ouvert. des Corps, 2 tomes. Paris, 1804.—Kade, in Reil's Ar- chiv. iv. p. 382.—J. Cruveilhier, Sur. I'Anat. Path log. kc. 2 vols. 8vo. Paris, 1816.; et Mid. Eclairie par I'Anat. et Phys. Path. cap. i. Paris, 1821.-, et Anat. Path, du Corps Hum. I. i.—xv. Paris, 1727 33.—Broussais, Hist. des Phlegmasies I hroniques, kc. t. ii. cap. 1. et seq.— Rev. in J. Johnson's Med.-Chirure. Rev. vol. ii. p. 1.— J. Abercrombie, in Ed. Med. and Surg. Journ. No. 84.-, et Dis. of Stomach and Abd Viscera, 8vo. Edin. 1828.— Tucheron, Recherches Anat. Pathol. &.c. 3 t. 8vo. Paris, 1823.—Andral, Recherches sur I'Anat. Palhol. du Canal Dig stif, kc. in Nouv. Journ. de Med. t. xv. p. 193.; et Lond. Med. Repos. vol. xi . p. 248. et seq.; et Anat. Pathol. 8vo. vol. ii. par. i. et seq.—J. B. Palletta, Exer- cit. Palhol kc. 4lo. Med. 1820 7.—Merat, in Diet, des Sciences M6d. t. xxxviii. p. 152.—X. Bichat, Anat. Pa- thol, ed. par Boisseau, 8vo. Paris, 1825.—A. N. Gen- drin, Hist. Anat. des Inflammat. vol. i. p-. 493. 659. 691. —Hutin, Nouv. Biblioth. Med. t. ix. p. 4. 328.—Foutf loud, Ibid. vol. v. p. 169.—Billard, De la Memh. Muquese Gastro Intest. dans I'Etal. Patholog. kc. 8vo. Pans, 1825.—Bourdon, in Rev. Med. t. ii. 1824, p. 209.— J. Annes/ey and Author, in Researches, &c. Dis. of Warm Climates, vol. ii. p. 39, et seq.—Craigie, Elements of Gen. and Pathol. Anat. 8vo. 1'28, p. 6'4.—J. Armstrong, Morb. An.it. of the Bowels, Liver, and Stomach, I. i. — iii. Lond. 1828.— A. Monro, Morbid Anat. of the Gullet. Stomach and Intestines 2d edit. 8vo. Edin. 183). ii. Lesions of Function and Circulation.— A. Of Function. Ried/in, Lin. Med. 1700, p. 173. —De Buchner, Diss, de Spasnio Intest. Erf. 1741. ; et De Consensu Primar. Viar. &c. Hal*, 1764.—Schneller, De Ardore Ventriculi, itc. Arg. 1786.—Danncnberg, De Asthenia Ventriculi et Intest. Ate. Jena?, 1801.—Wiesner, De Spasmo Ventriculi. Vit. 1802. -Burdin, in M.'m. de la Soc. Med d'Emula- tion, t. ii. p. 86.—Cheyne, Dub. Hosp. Rep. vol. iv. p. 252; —Macfar/ane, in Glasg. Med. Journ. vol. ii. p. 170. B. Of Circulation. — Blasius, Observat. Med. Rar. par. i. n. 21.—Hoffmann, Op. t. vi. p. 223.—Stoll, Rat. Med. par. viii. p. 129. — Katmpf, Abhan I. die Krank- heit. d. Unterlebs. tic. passim.—Bang, in Act. Reg. Soc. Med. Hafn. vol. i. p. 110., et vol. ii. p. 279.—Bleuland, Descrip. Vascul. in Intest. Tennjum Tunicis, kc. Traj. ad Rh. 1797, p. U.—Michaelis, Med. Bibliolhek, b. i. st. 3. p. 271. (Without pain or other sign.) —Yelloly, in Trans. of Med.-Chirurg. Soc. vol. iv. p. 228. — Trousseau, De la Dothinenlerile, kc. in Archives de Mid. t. x. p. 67. 169. —A. G'imaud, in Journ. Compl. du Diet, d s Sc. Med. July, 1820.—Schmidtmann, Observ. Med. t. ii. p. 98—181. — Goldmann, in Archiv. G6n. de Med. t. i. p. 278.— M. A. C. Landini, in Rev. Med. t. ii. 1826. p. 189. 398. (Of Mucous follicles.)—Leuret, Archives Gen. de M£d. L xvii. p. 453. (Mw. follicles.) iii. Atrophy, Hypertrophy, and Induration.— Schurig, Chylologia, p 560. (Atrophy.—Bonet, Sepulch. I. ii. s. vii. oh. 56. (Atrophy.)—Schenk, Observ. 1. iii. obs 92. (Atrophy. —Pohl, De Callositate Vent, ei Potus Spir. Abusu. Lips. mi.—Vetler, Aphorismen, i. p. 172 — 194. (Scirrhus to be seated in the cellular tissue.) — Le- velling, De Pyloro Carciaomatoso. Ing. 1777.—Sherwin, in Mem. of Med. Soc. of Lond. vol. ii. p. ""7.—Thilenius, Med. und Chirurg. Bemeik. i. p. 202.—Rwlolphi, Be- merkungen, th. i. p. 35.—Portal, Mem. sur Plus. Malad. vol. iii. p. l.—Baillie, Series of Eng. fas. iii. tab. 6. 7.— Cloquet, in Bullet, de la Soc. de Med. 1810. No. 7. p. 106.— Fournier, in Sedillot's Journ. de M6d. May, 1812—Dar- luc, Journ. de Med. t. xi. p. 499.—Smyth," in Med. Cora- munic. jcc. vol. i. No. 29.—Sims, in Ibid. No. 29,-^Har- rison, in Mem. of Med. Soc. of Lond. I. v. n. 16.—Haller, Opusc. Path. obs. 26. (From abuse of acids.)—Reil, Ar- chiv. f. d. Phys. b. iv. p. 381.—Horn, Archiv. f. d. Pract. Med. b. iii. p. 67.—Girdlestone in Med. and Phy-. Journ. vol. xl. p. 13.— J. Holmes, in Ibid. vol. xxviii. p. 170.— W. G. Burrell, in Ihid. vol. xxx. p. 515. -F. Chardel, Des D£g£nerat. Scirrheuses de I'Estomac. Paris, 1808. ; et iu Quart. Journ. of For. Med. kc. vol. ii.—Drake, in Edin. Med. and Surg. Jo irn. vol. ii. p. 417.— N. Hill, in Ibid. vol. xii. p. 275.—Greenhow, in Ibid. vol. xvii. p. 375.—Louis Mim. et Rech. kc. 8vo. p. 1-0. ; et Archives Generales, 4tc. t. iv. p. 53fi.—Bouillaud, in Re.. Med. Mars 1827.— R. Prus, Recherches Nouv. sur Cancer de I'Estomac. Stc. 8vo. Paris, 1828. iv. Softening, Ulceration, Erosiov, Perforation, Sic.—Bonet, Sepulchr. 1. iii. sect. xi. obs. 2, 3. 4, &c.— Morgagni. Sed. el Cans. Morb. ep. xxxv. art. 15.—Du- verney, Mem. de I'Acad des Scien. 1704, p. 27.—Haasius, De Tunica? Villosae Rcnovalione, kc. Altd. 1735. — Friend, Comment, de Febiibus, p. 142.—Hamberger, in Haller's Coll. Diss. Pract. vol. iii. n. 98.—R. Lowis, Edin. Med. Essays, vol. i. p. 291.—Van Swieten, Comment, kc. ad. § 955.—D. Monro, Essays Phys. and Lit. vol. iii. p. 516.—Gmelin, Ulc. Intest. Casus, &c. Tub. 1759.— Lieutaud, Hist. Anat. Med. 1. ii. obs. 719.—Geoffroy, Hist, de la Soc. R. de Mea. ad 1780, 1781, p. 162.—Bang-, Act. Reg. Soc. Med. Hafn. t. i. p. 280 —Feuron Mem. of Med. Soc. of Lond. \ol. ii. n. 38.—Field, in Ibid. vol. vi. p. 128.—Burrows, in Med. Facts and Observ. vol. v. n. 17. ; et in Trans, of Iii h Acad. vol. iv. n 12. (Fistula open, extern.) — Luchtmans, Diss. Med. Chir. Miscel. Ultr. 1783.—Haller, Opusc. Pathol, obs. 28. — Cruick- shanks Anat. of Absorb. Vessels, kc. p. 113. — Van der Kolk, Observat. varii Argument, kc. Gron. 1793. — Go- dot, in Journ. de M6d. t. xl. p. 145. —Jacquine/le, in Ibid. t. xc. p. 209.— HalU. in Ibid. Contin. iv. p. 103.—Nebel, De Ulcer, in Ventr. Penet. &c. Heid. 1782. Stoll, Rat. M d. i. p. 266., ii. p. 409., vii. p. 154. -J. Hunter, Philos. Trans, vol. Ixii. p. 444.; et Observ. on Animal. (Eco- nomy, 2d edit. p. 226.—B. Gooch, Med. and Surg. Ob- serv. &c. ; et in Edin. Med. Comment, vol. ii. p 373.— C. Smyth, Med Cominunicat. vol. vii. p. 467.—Adams, On Morbid Poisons, &.C. 2d ed. p. 30.— Ludwig, De Lumbri- cis Intest. Perforant. Lips. 1792—J. P. Frank, Acta Institut. Clin. Viln. ann. ii. p. 7.; et De Cut. Horn. Morb. 1. vi. par. i p. 131.—M'Lagan' in Ed. Med. Com- ment, vol. ii. p. 78. — Penada, Sa gio d'Osservazioni, t. i. —Keppelhout, Sect. Cadav. Pathol. 1805, p. 19.—A. Ge- rard, Des Perfor. Spontanees de I'Esto i ac, kc. 8vo. Paris, 1803.—J. Moore, in Med. and Phvs. Journ. vol. iii. p. 511.—A. Bellot, in ibid. vol. xxii. p."392.—W. Cooke, Ibid. vol. xxx. p. 337.—G. E. Male, in Ibid. vol. xiii. p. 164.—Chaussier Halle, et Leroux, in Bullet, -'e l'Ecole de Med. de Paris, 1808, p. 41.—A. Burns, in Edin. Med. and Surg. Journ. vol. vi. p. 137 —Heim, in Horn's Ar- chiv. Jan. 1812, p. 12.—Hanius, in Ibid. 1812, p. 162.— F. Davis, in Loud. Med. Rev. vol. v. p. 258.—Jaeger, in Hufeland u. Him/y's Journ. d. Pract. Heilk. May, 1811. ; et in Lond. Med. Repos. vol. x. p. 416. — Gistren, in Hufeland's u. Him/y's Journ. d. Pr. Heilk. July, 1811.— Michae/is, in Ibid. Feb. 1812, p. 45.—Marcus, in Ephe- merid. d. Heilk. b. i. st. 2.—Lallemand, Observ. Palh. &c. 8vo. Paris. 1818. 4to.—Stiitz, in Hufeland's Journ. d. Pr. Heilk. b. xxr. p. 83. — Schenk. in Ibid. b. xxvii. p. 89.—Zel/er, De Nat. Morbi Ventric. Infant. Peiforan- tis. Tub. 1818.—Bre chet, in Journ. de Med. Contin. t. xi.—F. Rhodes, in Horn's Archiv. Sep. et Oci. 1822, p. 238 —Laisne, Consid. Med. Leg. sur les Erosions et Perfor. de I'Estomac, 8vo. p. 163.—C. Broussais, Bullet. de la Soc. Philomath. Sept. 1823, p. 156.—Haviland, in Cambridge Philosoph. Trans, vol. i. p. 287 —J. Guirdner, 'ases of Erosions and Perforations of Aliment. Can. A/c. Train, of Edin Med. Chir. Soc. vol. i. p". 311. (An able memoir.)—P. C. A. Louis, M£m. et Recherches Anat. Path. *;c. 8vo. Paris, 1826, p. 1. 136. : et in Archieves de Med. t. i. p. 17., et t. v. p. 5 ; et Lond. Med. Repos. vol. xxii. p. 154.—Legullois, in Archives de Med. vol vi. p. 68.—Trail'let, in Ihid. t. ix. i>. 5. -Ebermaier, in Ibid. t. xviii. p. 427.—Rullier, in Ibid, t ii. p. 380 —Lisle, in Ibid. t. xx. p. 433.—Chaussier, in Nouv. Journ. de Mid. t. iv. p 295.—Hewett, in Med. and Phys. Journ. vol Ivi. p. 97.—Chambers, in Ibid. p. 354.: and in Lond. Med. Gazette, vol. ii. p. 513. — Bright, Medical Reports, vol. i. 4to. p. 178.— W. E. Horner, in Amer. Journ. of 556 DISEASE — Causation and Doctrine or. Med. Scien. Feb. 1829.—Laennec, in Rev. Medicale, t. i. 1824 p. 379.—Conner, in Ibid. t. iv. 1825, p. 527. ; et in Arch vcs de Med. t. xviii. p. 427.— Sestic, Journ. Heb- domad, de Mid. 1. i. p. 216.—Pitschaft, Edin. Med. and Surg. Journ. vol. xxvi. p. 451.—Glasgow Med. Journ. vol ii. p. S4l.—Hediard, Journ. des Progres des Scien. Med. t. xvi. p. 250.—E. Blasius, in Rust's Mag zin f. d. Gesamra. Heilk. kc. vol. xxvii. ; et Journ. Hebd. de Med.LH. p.69.(Gelatinifo msoftening.)—C/oquet, Nouv. Journ. de Med. t. i.; et Lond. Med. Repos. vol x. p. 332. —Billard, Nouv. Biblioth. Mid. L i. 1826. p. 42.—Wiese mann, Lond. Med. Repos. vol. xxv. p. 168.—Dupuy, in Ibid. vol. xxvii. p. 373. — Rogers, in Ihid. vol. xxviii. p. 219.— B. Brown, in Ibid. vol. xvii. p. 103.— Carter, in Ibid. vol. xxi. p. 371.—M. Workman, in Ibid. vol. xix. | p. 2)8.—Coste. in Ihid. vol. xx p. 212.—Crampton, Trans. of Irish Col. of Phys. vol. i. part i. ; and in Trans, of Med. and Chirurg. Soc'vol. viii. p. 228. -Chevalier, in Ibid. vol. v. p. 93.—Elliotson. in Ibid. vol. xiii. p. 26.—Trovers, in lb d. vol. viii.—Abercrombie in Edin. Med. aud Surg. Journ. vol. xxi. p. 6.—Laennec, Rev. Mid. Mars, 1824. —Carswell, in Edin. Med. and Surg. Journ. vol. xxxiv. p. 283. (An excellent memoir.) v. Morbid Secret onsa d Productions.—Rivei-ius, Observ. cent i —Fabricius Hildanus, cent. ii. obs. 64.— Morgagni, Epist. xxxv. art. 25.—Blasius, Obs. Med. Rar. p. vi. ob. 3.—Sand, De raro Ventric. Abscessu. Reg. 1701. —Stenzel, De Steatonatibus. kc. Viteb. 1723.—Hasen- oehrl, Hist. Febr. Petech. p. 67 —Niesky, De Humor. Intest. Ten. Path. Consideratis. Halae, 1766.—Sprogel, De Morb. Huinorum in Intest. Hal. 1766. — Haller, Opusc. Pathol, oh;. 27.—De Haen, Rat. Med. p. vi. cap. 4. § 10.—Watson, in Med. Communicat. kc. vol. ii. —Oberleuffer, Mils. d. Heilk. b. i. No. 16. — Osiander, Denkwiirdigkeiten, i. p. 403.—M. Baillie, in Transact, of Coll. of Phys Lond. vol. v. p. 166.—R. Powell, in Ibid. vol. vi. p. 106. — Martinet, Journ. de Mid. t. xxviii. p. 244— Godman, Philad. Journ. of Med. May, 1825.— Seymour, Trans, of Med. Chir. Soc. vol. xiv. p 222.— Lherminier, in Ed. Med. and Surg. Journ. vol. xxvi. p. 214.—Bourgeois, in Archivs de Med. t. xi. p. 137.— Annesley, Sketches of Dis. of India, chap, on Dissect. in Cholera, 2d ed. 1829.—Also the works of Cha del, Vetter, Monro, Louis, R. Prus, Cruveilhier, Armstrong, Merut and Abercrombie, already referred to. vi. Changes of Capacity and Position.—Bartholin, Hist. Anat. cent. iv. n. 40.—Bonet. Sepulchret. I. iii. sect. 14.-Plater, Observ. 1. ii. p. 439.. et I iii. p. 656.— Kerkring, Spiceleg. Anat. obs. 50.—Schacher, I»e Morbis a Situ Intest. Praeternat. kc. Lips. 1721.—Morgagni, Epist. xxxix. art. 15., liv. art. 15.—Walther, De Intest. Angustia, kc. Lips. 1731.— Hamberger, Observ. Clinic. Jen. 1754, p. 10.—Meckel, in Mem. de I'Acad. de Berlin, 1758, p 68.—Felix', De Intestin. Intus-susceptione. Lug. Bat. 1769.—La/ouette, Hist, de la Soc. R de Med. ann. 1776, p. 267.—L'oesec'e, Observ. Anat &c. p. 29-37.— Huxham, in Philos. Trans. No. 3 2.—Van Doeveren, ' Specimen. Observat. &c. p 76. (Diverticula )—Troeschel, j De Morb. ex alieno Situ Part. Ahd. kc. Franc. 1754. — Base, De Diverliculis Intestin. Lips. 1779.—Lieutaud, | Hist. Anat Med. obs. 27. — Hasenoe.hrl, Hist. Morb. j Epidem. p. 60.—Bung, Diarium, ii. p. 367.; et in Act. Reg. Soc. Med. Hafn. vol. i. p. 243. — Callisen, in Ibid. vol. i.— ! Stoerck, Annus Med. i. p. 126., et ii. p. 268.—Roth, Diss. I Path. Intest. Coli. p. 14.-De Haen, Rat. Med. par. x. § i. I —Mollinelli in Comment. Bonon. t. ii. p. 1 — Sandi- for , Observ. Anat. Path. I. i. c. 10., et 1. iii cap 3. p. 59., 1. iv. cap. 2. p. 28 — Schneider, Clin. Geschichte, b. v p 86. I —Anderson, in Ed. Med. Comment, vol. ii. p. 302.—Hal j ler, Opusc. Path. obs. 27. -Mursinna, N. Journ. f. d. Chirurg. b. i. p. 241 —J. P. Frank. D Cur. Horn. Morb. I. v. par. ii p. 391., et I. vi. par. i. p. 53.—Lettsom. in Philos. Trans, vol. lxxvi p. 305—Rahn, Diss. Pass. Iii- aeae Path. Hala;, I791.-Z.ee, in Lond. Med. Rev. June, 1801.—Fruncis, in Med. and Phvs. Journ. vol xxxv. p. 436. -Portal Anat. Med. t. v. p. 188. 208.—Treuner, iu Stark's S. Archiv. kc. b. i. p. 241., h. ii. p. 91.—Mezler, in Hufeland's Journ d. Pr. Heilk. July 1811. p 24.__ Andral, Journ. de Physiol. Aoul, 1822.—J. Duvies, Lond. Med. Repo . vol. xxii. p. 469.—Micha lis. in Ibid Feb. 1812, p. 39— J. F. Meckel, Beitr b. i. h. 1.; et Comp. Anat. Path t. i. p. 553.—Mollison, in Trans, of Med. Chiiurg Soc. of Edin. vol. ii p. 249.—Rostan, Ar- chiv. Gen. de Mtd. t xix. p. 332. DISEASE — the Causation and Doctrine of. — Classif. General Pathology; Etiology and Pathogeny. 1.1. Preliminary Remarks.—Itis of great importance to the tyro in medicine to acquire general principles, derived from a careful and comprehensive investigation of disease, that may guide him in the practical course he has to pur- sue. Nor is it of less moment to the experienced to find inferences and doctrines calculated to serve as the basis of therapeutical indication* deduced for him even from those phenomena which have become familiar from frequent obser- vation, or have appeared trivial when viewed in an imperfect or false light. It is by an intimate acquaintance with morbid actions, in respect of their origin, of their conditions at the time of ob- servation, and of their tendencies, and by a know- ledge of principles derived therefrom, that we are chiefly enabled to direct our course through those numerous difficulties which beset us in the practical discharge of our duties, when we are insufficiently aided by published authorities, or imperfectly guided by the results of personal observation. Even the most experienced will often find examples of disease in some one or other of the numerous combinations or succes- sions it is constantly assuming, of which memory will not furnish sufficient examples, by the re- sults of which he may be guided; and will fre- quently have to recur to those principles, both doctrinal and practical, which he had learnt from his predecessors, or had acquired for himself by analysing and recombining the numerous mani- festations of morbid action which have been presented to his view. In endeavouring to sup- ply what is not to be obtained in our medical literature—to satisfy a want which I know has been very generally felt—I have only to regret that my limits will preclude those details, which many might require, and will confine me chiefly to succinct statements, where vivid illustrations might be necessary, and therefore looked for. But some advantage will be derived from ex- hibiting an outline of the subject, in a methodic manner, filled up in its more essential parts with such touches and shades as may be neces- sary to truth of representation, and treated in separate articles where it assumes a practical interest. The origin of disease, and the nu- merous circumstances, which, existing either intrinsically or extrinsically in respect of the frame, modify disease1 in its progress, are amongst the most important topics to which the mind of the scientific practitioner can be directed; inas- much as upon a due recognition of these, in their individual or joint operation, will depend the just- ness of our indications of cure, the appropriate employment of remedies, and consequently the success of -our practice, and our own eminence. 2. i. The intimate Relation of the Subject to the Doctrine of Life.—In all speculations re- specting the causes, the nature, and the removal of diseased actions, the body ought to be con- sidered in relation — 1st, to its organization and mechanism ; and, 2d, to the influence by which that mechanism is actuated: we should view it as presenting an assemblage of numerous and beautifully contrived parts, all displaying a wonderful and harmonious combination of phe- nomena,—the most perfect and the highest pre- sented to us in the physical world. Some of the finest illustrations of mechanical adaptation and power, and of those principles of action to which the researches of the natural philosopher have been directed, are manifested in the human body. But these manifestations are subject to a finer and DISEASE — Causation and Doctrine of. 557 yet a more powerful principle than any which govern the operations of inanimate matter. The whole organized creation, especially the higher animals, and man in particular, display functions which inanimate substances cannot produce; and although physical actions are observed in their most admirable conditions in the animal body, they are entirely subject to higher functions, to which the term vital, from their nature and object, has been applied. It is one of the chief characteristics of life that it is allied to matter, delicately and peculiarly combined, and differ- ently constituted from inanimate matter, which is kept in a state of cohesion by means of the attraction subsisting between its particles, and which state its chemical affinities dispose it to preserve. Life allied with matter produces com- binations entirely different from those, which the chemical affinities of the elementary particles dis- pose them to assume, and preserves these combina- tions in opposition to their physical tendencies as long as it continues thus associated. Life, then, as I have already contended, is a superior power; and this superiority is instantly shown by the readiness with which the elementary particles of that mat- ter with which it is so intimately connected enter into different combinations and forms as soon as this principle is withdrawn. One, therefore) of the chief, although apparently one of the lowest and most generally diffused manifestations of life, is to preserve the textures, or the matter with which it is associated, in a state suitable to the performance of the various functions of the ani- mal. But it also executes higher offices. By a series of beautiful processes, it changes sub- stances foreign to the constitution of the animal to which it is allied, and at last assimilates them into the organized structures which it animates. Thus nutrition and growth are produced, and the decay of the organized body is prevented. 3. Life, in its intimate alliance with the struc- tures of the body, gives rise to various manifest- ations, according to the peculiar organization of each; these structures being the instruments of its ] influence, and the organs by which vital operations are performed. Thus the muscular fibre, endowed ' with life, displays contractile properties, the nerv- ous fibriles manifest sensibility; the liver and kid- neys perform their secreting functions; and so on as respects the various parts composing a perfect ani- mal. The healthy functions of life form the study of the physiologist, whilst the description of the organs performing them belongs to the anatomist. It is with the derangements of both functions and organs, that the pathologist and practitioner are | chiefly concerned. The knowledge of structure j and healthy function is, however, the basis on which both the one and the other raise a super- structure of great public benefit. The duly instruct- ed pathologist is enabled to comprehend the beau- tiful combination of physical principles evinced by the human body; and to understand how they are directed by, and made subservient to, life, whether in perpetuating its healthy duration, or in guarding it against agents threatening any j of the functions and organs which it endows,! or in removing derangements when'actually pro- j duced. It is from an enlightened recognition of! the operation of external agents on vital func- tions, of the relation subsisting between causes and their effects, and of the succession of mor- 47 bid phenomena consequent on primary changes, either vital or organic, that the scientific practi- tioner is enabled to devise suitable plans and appropriate means of restoration to the healthy state. But, when contemplating the functions of the living body, whether in health or in disease, he should not restrict his considerations either to the physical, or to the vital, phenomena which any particular organ or structure presents. He should recollect that the physical phenomena are under the direction of the vital power; and that this power, although influenced by mechanical or physical operations, is equally energetic in controlling these operations, as they are, in their turn, of controlling it. The pathologist «iust be aware that the study of the living frame in health, and more especially in dis- ease, is the investigation of the numerous man- ifestations of life through the various organs and structures with which it is wondeifully and inexplicably associated. Of life itself we know nothing but through those manifestations, and thus it is through them only we can en- quire respecting its conditions. Although we can- not demonstrate the intimate nature of vitality, and cannot show the peculiar ties which bind it to organization; we can prove, by an accurate enquiry into the numerous phenomena exhibited by living bodies, and by the manner in which ex- ternal agents modify these phenomena, as well as by the derangements evinced by particular organs and structures, that the connection is intimate, and that causes operating upon the one generally affect the other. '1 his powerful influence of life over the functions of the organs with which animals are endowed, and the manner in which causes modify the conditions of this principle, whether acting immediately upon it, or through the medium of the organization with which it is allied, are amongst the most important topics which interest the medical practitioner. 4. The conditions of life, as manifested in the functions either of a single organ, or of the frame generally, are liable to change, from in- trinsic and extrinsic causes ; and the resulting alterations modify the structures with which this principle is so intimately and mysteriously re- lated. On the other hand, the states of the animal organs and textures are readily affected by agents acting directly upon their organization; and these states of structure modify its vital manifestations, and, through them, the vital en- dowment of the body generally. From this mutual dependence—this reciprocative influence —it will appear that, as life can only be contem- plated through the medium of an organized body, so the derangements of such a body cannot be accurately investigated, and the conditions of life —its manifestations in appropriate systems and organs — be left out of consideration. 5. ii. Health and Disease defined.—Whilst the energy of the vital endowment is uninjured, and its manifestations in the various systems are in due harmony throughout, and with the state of the structures with which it is associated, all the operations of the body are duly and steadily performed. This is the condition which may be termed health. But as soon as the energies of the vital principle become depressed, excited, exhausted, or otherwise altered, either through- out the body, or in any of the systems or organs 558 DISEASE—Causation of — ^Etiology. by which it is manifested, and when change from the natural condition is primarily produced in any of the structures with which it is asso- ciated, disease supervenes. This aberration from the natural condition of the vital energies en- dowing the whole, or parts of the frame, or alteration of the textures which these energies actuate, is produced by causes acting sometimes singly, occasionally in combination, and fre- quently in succession. To point out the nature and modes of operation of those causes upon the living body, as far as their natures and effects are known, is the object here proposed. 6. A knowledge of the causes inducing those changes ; the nature of the changes produced, as respects either the vital manifestations, or the, structual alterations ; the signs or phenomena by which morbid conditions of vital function or of structure are recognised ; are the chief topics which interest the pathologist; whilst the means of removing those disorders, of averting death, and of alleviating the sufferings which they oc- casion, when cure is beyond the reach of our science, are the ends which he proposes to him- self as the reward of his investigations. In order that all that is advanced respecting the various kinds and states of disease may be more clearly un- derstood, I propose to give, in this, and some ar- ticles that will be referred to, a sketch of patho- logical principles; so that, by pursuing the plan pointed out in the preface, the knowledge which the tyro or the inexperienced reader will have acquired from this part of his systematic course of study, will become serviceable to him in the acquisition of that which should be afterwards brought be- fore him. By considering what is simplest and most elementary, and proceeding onwards to what is more complicated and difficult, the mind will be gradually enabled to understand the abstract subjects which will come before it; the know- ledge successively acquired introducing it to an acquaintance with what will follow. Before treating of the principal states or alterations from the healthy condition of the frame, which con- stitute the disease, I shall point out, first, the causes which act upon the living body most fre- quently in an injurious manner ; secondly, the morbid conditions themselves which these causes induce; and, thirdly, enquire (in a distinct article) into the symptoms by which the nature of these conditions are recognised. Hence, disease will ap- pear as a series of changes resulting from causes, between which and their effects there is a most intimate, although not always an obvious, relation. 7. II. Causation of DisEASE,or Etiology. from ulnu, cause, and ■•■uy'uc, a discourse. Causes act primarily on the vital endowment. — I have already stated, that although the va- rious textures and organs of the body display the finest combinations of mechanism, and the most beautiful principles of action presented by the physical world, yet they are entirely under the dominion of life, by which only they are ac- tuated, and on which they entirely depend for the functions they present. It is not upon the tex- tures or organs themselves that the causes of disease generally make their first impression; and even when they are brought in immediate relation to a particular organ or structure of the body, we have no evidence to furnish that they derange these parts by primarily affecting the machinery of which they are composed; but, on the con- rary, from the gradual manner in which de- rangement is produced, from the nature and effects of the disorder which follows, and nume- rous other considerations, it may be inferred that they make their first impression upon the vital endowment of the organ, disordering the func- tions which it performs under the dominion of life ; and the functional disorder either leads on to the production of further disease, or indirectly to a return to the healthy condition. No doubt, some causes affect at once the organization of the part, such as many chemical, physical, and mechanical agents; but the majority modifies the vital manifestations of the frame, either in one organ or structure, or in several simultaneously; and by impeding or modifying, deranging or altogether changing these manifestations, thereby induces effects, which become themselves causes of further disease, until life itself is terminated, or a healthy condition of function re-established. Of the justness of this inference satisfactory evidence will be furnished in the sequel. (See § 63., et seq.) 8. The causes of disease have been variously arranged and named by pathologists. For the better understanding the subject, and writers on disease, the different arrangements and distinctions which this subject has received may be briefly alluded to. Causes have been denominated ex- ternal or extrinsic, and internal or intrinsic, according as they operate upon the body from without or within. They have also been called principal and accessory or concurrent; disease proceeding chiefly from the former with the as- sistance of the latter. They have also been named positive and negative, from the manner in which they act upon the body: and by some they have been divided into physical, chemical, and physiological, according to their nature. The division, however, which has been most generally adopted is into remote and proximate or imme- diate, according to their relation to the disease occa- sioned by them : the remote being the first in the chain of causation, the proximate or immediate those early changes which they effect in the ceco- nomy, and which constitute the primary condition of the disease, or, in other words, the patholo- gical states arising directly from the operation of the remote agents. The remote causes have been divided into predisposing and exciting or oc- casional causes ; the predisposing being those which influence the conditions of the living func- tions so as to favour the operation of those occa- sional or exciting causes whence disease more di- rectly springs. To these two classes I would add a third, viz. determining or consecutive causes, which, being posterior to the others in point of time, determine or call into action the exciting causes, or rather come in aid of, and follow up, the impression made by the latter ; and which, without such aid, might have been insufficient to produce actual disease, or would have induced it only in a slight degree. 9. It must be obvious that all causes, as well as the effects they produce, must have an in- timate relation to the condition of the living frame; and that those which may be quite in- efficient on one person will be powerfully active on another; or which are without effect on an individual at one season, will be very influential at another, owing to the state of vital energy at DISEASE — Predisposition to — /Etiology. . 559 the time, to the concurrence of other causes, or to exposure soon afterwards to such as will de- termine, or otherwise aid, those which preceded it, and which, although the principal or exciting causes, were insufficient, until thus reinforced, fully to produce the disease. Owing, also, to the condition of the frame, no effect will some- times follow one, two, or even three exciting causes; and until a greater number are brought into operation, no mischief will often result. The effects produced by various animal and vegetable exhalations on different individuals, or upon the same person at distinct periods, under different states of mind and predisposition ; and by the action of numerous concurrent, accessory, and determining causes ; fully illustrate this position. It is chiefly owing to a want of knowledge of the doctrine of causation, that so much error and difference of opinion prevail respecting infectious and non-infectious diseases. On the other hand, persons may be so very easily affected, that causes of the slightest nature, and such as are determining or accessory in the majority of cases, are principal in respect of them; and in- fluences which are usually predisposing are often, in such persons, the exciting causes of disease. Also those which are remote in their operation on some constitutions, are direct or immediate in respect of others. Examples of this are found in the diseases of the lungs, liver, stomach, and bowels. In considering the agents which affect either the functions, or the organization, I shall first notice those which generally predispose the system to disease; next those which excite dis- ease in a direct or immediate manner; afterwards such as are specific, or produce determinate results; the effects of their operation on the living frame being obvious, and often admitting of being foreseen; and lastly those circumstances which sometimes determine, reinforce, or call into action, exciting or specific agents. 10. i. Of the predisposing Causes of Dis- ease.—These may be classed—1st, into such as are proper or peculiar to individuals, and the cir- cumstances in which they are placed; 2d, into such as are not proper or peculiar to individuals, but which may affect various persons, and even numbers of persons, but individually and occa- sionally; and, 3d, into such as are general, and affect more or less all who are exposed to them. —A. Those which are peculiar to the individual, and to the circumstances in which he is placed, and which may be called the individual predis- posing causes, are—1st, original conformation and hereditary predisposition, age, sex; tempera- ments, original and acquired ; habit and consti- tution; trades, professions, and circumstances of life, &c; and, 2d, the various external and inter- nal agents, and circumstances modifying the state of the functions,—as previous functional disorder, and convalescence from disease ; and the preg- nant and puerperal states. 11. a. Original conformation and hereditary predisposition.—It is generally observed, that the constitutions, temperaments, and diathesis of the offspring closely resemble the parent ; and that whatever disposition to disorder, whether of func- tion or of structure, the latter may have pos- sessed, is liable to evince itself in the former. From this circumstance having been very gene- rally remarked in respect of certain maladies, they have been termed hereditary. But it must not be supposed that children are actually born with the diseases of their parents. This is but seldom remarked; although, in rare instances, I have observed the commencement of tubercles in the lungs of a new-born infant by a consumptive mother; and small-pox and syphilis are some- times communicated to the foetus in utero, occa- sioning in some instances its premature birth, and even its death, either previously to or about the natural termination of utero-gestation. Hy- drocephalus, cataract, and various imperfections of the organ of hearing, and, indeed, of other organs of sense, are not infrequently congenital, or examples of disease from original conform- ation ; but, in such cases, it is rare that the parent is similarly affected at the time, although the hereditary predisposition, as about to be ex- plained, exists nevertheless ; and, as respects the first of these, a tendency merely to the disease could have existed at an early age in the parents. It should be kept in recollection, therefore, that the foetus in utero may be affected by several cachectic, inflammatory, or even febrile diseases, communicated by the parents, or supervening accidentally : but, of those which are thus com- municated, even the majority are not, properly speaking, hereditary; and those which are acci- dental do not depend upon the constitution of the parents, or the ailments experienced by the mother during the period of gestation. Con- genital diseases are consequently divisible into— 1st, Those which occur in the foetus, without any participation on the part of the parents,— as imperfect developement of organs, inflam- mations, effusions of fluid in various parts, &c.; 2d, Diseases in which the foetus participates with the mother, owing to their contaminating influ- ence, or their extension throughout her organiz- ation,—as syphilis, small-pox, fevers, &c.; 3dly, Those that affect the foetus from a constitutional liability in one or both parents,—as hydroce- phalus, cataract, tubercles, &c. 12. Most commonly, however, the child is born free from disease; but, inheriting the constitution and diathesis of the parent, has that condition of function and organization which renders it more susceptible of impressions produced by the exciting causes of certain maladies. Examples of this may be contemplated daily in re:-pect of diseases of the lungs and brain; the constitution and functions of these viscera disposing them or rendering them more prone to experience those derangements by which the parent or parents had been affected. In some instances this pre- disposition may be more strongly marked in the child than in the parent; and in other cases the predisposition may be extremely slight, and only brought to light by the operation of the more energetic agents. 13. The predisposition of the offspring gene- rally evinces itself more strongly at certain ages than at others, according to the kind of morbid constitution or predisposition which it may in- herit, the causes to which it is exposed, and the nature of the malady which results. Thus, the disposition to hydrocephalus, convulsions, idiotey, rickets, scrofula, cataract, &c, is most apparent soon after birth, and at early epochs of life; to epilepsy, hamorrhage, and pulmonary consump- tion, about the age of puberty, or previously, or 560 DISEASE — Predisposition to — ^Etiology. 60on after; to gout,asthma, and angina pectoris, in adult and mature age; to insanity, apoplexy, and paralysis, during the mature or advanced stages of life; and to various nervous disorders, at more irregular periods. But these diseases do not necessarily supervene, although one or both pa- rents have been affected by them ; and several usually appear in alternate generations. Some occur more uniformly than others. When the predisposition to them is derived from only one parent, they very frequently never make their appearance, unless as the effect of very active ex- citing agents. But even when the predisposition is derived from both parents, and when it may be con- sidered as being thereby heightened, exciting caus- es are generally required to develope the disorder. 14. b. Age.—Each of the different epochs of existence is more liable to certain diseases than to others. During the earlier periods, there is generally a predisposition to particular disorders, even when no hereditary taint exists. This is partly owing—(a) to the changes going on in the frame; (b) to the state of vital manifestations ; and (c), to irritations in the alimentary canal. Amongst the changes proceeding in the frame, that either readily suffer derangement or lead to it, the most important are the processes of ossification and developement of the contents of the cranium. These processes are more or less under the do- minion of the vital influence; and they are more or less disturbed as this influence is affected, in respect either of the system generally, or of particular organs. Hence, rickets, hydrocepha- lus, inflammations of the brain or its membranes, readily occur. The quantity of blood sent to the brain in early life is another predisposing cause of cerebral affections ; and the readiness with which the functions and even the circula- tion of the brain are disturbed by impressions from without or by irritations from within, becomes, especially when assisted by other causes, a fre- quent source of disease. (See Age, § 10.; and Dentition.) 15. After the first dentition, and during growth, the powers of life are energetic, as shown by the reaction of the vital functions upon the depress- ing causes of disease; and are eminently conser- vative, particularly in resisting hurtful agents. The predisposition is chiefly to inflammatory ail- ments and acute attacks of fever, especially iu those who breathe a wholesome air and are sufficiently nourished. But the susceptibility to impressions, both moral and physical, is energetic; and irritations, from whatever cause, are gene- rally followed by augmented vascular action, with which the whole frame, owing to the sus- ceptibility of the nervous systems, promptly sym- pathises. Hence febrile attacks, eruptive fevers, inflammations, cerebral affections, disorders of the air passages, of the alimentary canal, and lymphatic glands, usually appear. At this period, also, all specific causes readily take effect, par- ticularly of those diseases which are incidental to childhood; their full operation, however, destroy- ing the susceptibility to be again affected by them. About the time of puberty and adoles- cence various complaints first show themselves, especially some that are inflammatory, and to which there is an hereditary tendency,—as pul- monary consumption, haemorrhage from the lungs, epistaxis, plethora; and as soon as the body has ceased to grow in height, or the vessels to ex- tend themselves in the direction of their axis, these disorders are still more readily produced by exciting causes. In manhood and mature age,the susceptibility to impressions gradually diminishes, and generally continues to decrease as age ad- vances. During the former of these periods, hypochondriasis, melancholy, insanity, hreiiior- rhoidal affections, asthma, rheumatisms, and the majority of organic diseases, with the exception of such as are scrofulous, commonly make their appearance. Towards the decline of life, gout, softening of the brain, apoplexy, paralysis, scir- rhus, cancer, changes in the coats of the blood- vessels, diseases of the organs of sense, affections of the urinary passages, &c. usually supervene. (See Age, and Climacteric Decay.) 16. c. Sex.—There are a great many dis- eases to which both sexes are equally liable. Fevers, inflammations, organic diseases, and many others, attack both. But it has been observed, during the prevalence of epidemics, and in un- healthy countries, that the female sex suffers much less than the male. This, no doubt, arises from the more regular habits of females, and their less exposure to the determining or concurring causes: something may also, perhaps, be attributed to their periodical discharges, which tend to dimi- nish plethora and to purify the circulating fluid- circumstances calculated to impart a partial ex- emption from several diseases, particularly those which are epidemic and endemic, although they may dispose to others. But the conformation and temperament of females, the sympathy exist- ing between their generative organs and the state of the circulation in the brain, the marked sus- ceptibility of their nervous system, and great mo- bility of their muscular organs, dispose them— especially those in cities and populous towns—to diseases usually denominated nervous. The natural vicissitudes, also, of female Jife are accompanied with a tendency to particular maladies, especially the periods at which the menstrual discharge com- mences and ceases ; at the former of which, nervous and cachectic complaints—at the latter, diseases of the organs of generation, or of those closely allied to them in function or situation— very frequently appear;—chorea, chlorosis, irre- gular convulsions, hysteric or painful affections, difficult, suppressed, or irregular catamenia, oc- curring about the former epoch; and chronic in- flammations, scirrhus,cancer, and other organic le- sions of the womb, disease of the breast, and disor- ders of the colon or rectum, about the latter period. 17. d. Temperament and diathesis.—The san- guine and irritable temperaments dispose to ple- thora, inflammations, haemorrhages, pneumonia, and to inflammatory fevers. The bilious tem- perament most readily experiences biliary de- rangements, bilious fevers, affections of the stomach and bowels, hypochondriasis, mental disorder, chronic cutaneous eruptions, and various organic derangements of the abdominal viscera. Persons of the lymphatic or phlegmatic temper- aments are predisposed to catarrhal attacks, slow fevers, chronic discharges, dropsies, scrofulous and scorbutic affections, diseases of the joints and glands, and to tuberculous and other chro- nic diseases. In persons thus constituted, the powers of life are languid, the preservative in- fluence and vital resistance feeble, and reaction DISEASE — Predisposition to—^Etiology. 561 upon noxious causes or agents seldom developed or energetic. The nervous temperament disposes chiefly to convulsive diseases, especially to hy- steria in the female sex ; to mania and insanity, or other derangements of the mental manifest- ations, as hypochondri;isis, melancholia, &c. ; to nervous and typhoid fevers, &c. This tempera- ment often modifies the progress of various acute diseases, and imposes upon them a nervous cha- racter. When the temperaments are mixed, an accordant predisposition may often be remarked ; as, in the sanguineo-bilious, a disposition to bil- ious inflammatory fevers, to hepatitis, to inflam- mations of the alimentary canal, of the brain, and of the serous surfaces, &c, is often manifested. 18. e. Of constitution and habit of body, it may be remarked, that a robust constitution gen- erally successfully opposes the impressions of many exciting causes ; but when once a morbid impression is produced, disease assumes a more active or acute character, and is attended with higher vascular action, the powers of life and reaction being great. On the other hand, weak constitutions, and those of a scrofulous taint, are more disposed to disorder, more readily affected by iu causes upon the first impression ; and disease in them assumes a more chronic and low form. When persons thus constituted have become habituated to the impression of certain morbid agents, they frequently cease to be affected by them in the usual manner ; as observed in respect of marsh or terrestrial emanations, which seldom give rise to regular attacks of fever in such sub- jects, but induce organic disease, and sinking of the powers of life. 19. /. Habits of life and profession are amongst the most influential predisposing causes of disease. Whatever profession or occupation requires an active exertion of the powers of the mind, and continuation of that exertion to the neglect of sufficient relaxation and exercise, occasions deter- mination of blood to the head, and favours the production of inflammation of the brain or of its membranes, especially if such persons live fully or luxuriously ; and, if fever attack them, the head, the liver, and stomach become severely and dangerously affected ; and, unless the disease be actively treated at its commencement, death may supervene in consequence of serous effusion from the membranes, or of softening of the tex- ture of the brain, rupture of its vessels, or of or- ganic change in the liver or digestive canal. Those who take active exercise in the open air are generally more disposed to inflamma- tory attacks of an acute character, to pneu- monia, and to rheumatism, than to other com- plaints ; although in them the predisposition to disease is much less than in other persons. Those who indulge the appetites beyond what the eco- nomy requires,— especially the desire for food, and for vinous and spirituous liquors,—are liable to disorders of the stomach, liver, and intestinal canal; and, if attacked by fevers, these organs generally are the most seriously affected : such indulgences also dispose to plethora, apoplexy, paralysis, gout, dropsy ; and in many cases direct- ly excite those maladies. Inordinate sexual inter- course is also a frequent predisposing cause of many diseases, and often immediately induces disorder. Pulmonary disease, affections of the heart, epilepsy, mania, and the other disordered manifestations of mind, frequently take place in consequence of the predisposition to them gener- ated in the system by the excessive indulgenceof this appetite. It also leads to other maladies, by lowering the vital energies of the frame, and thereby rendering them more assailable by the common exciting causes of disease. 20. gr. The circumstances of life in which per- sons are placed have a marked influence in favor- ing or counteracting the operation of exciting causes. It has been determined, by exact observa- tions and calculations, that those who enjoy easy or comfortable circumstances are much less sub- ject to disease than the poor, the insufficiently clothed, aud ill-fed. This arises not only from the former class being less exposed to its exciting causes, but also frpm the good effects of sufficient nourishment in supporting the energies of life, and thereby warding off the impressions of injurious agents and influences. Much, also, is owing to personal and domestic cleanliness, to proper cloth- ing, and to living in airy apartments in healthy localities. Yet, while full living thus wards off many diseases, especially those arising from de- bility, as low or adynamic fevers, scorbutic dis- orders, scrofula, dysentery, and various others, it disposes to gout, dyspeptic and nervous affections, particularly to apoplexy and paralysis. (See Arts and Employments.) 21. h. Debility, previous disorder, and con- valescence from other diseases, often favour the operation of exciting causes; particularly when the powers of life are much depressed or exhaust- ed. In respect of the predisposition occasioned by already existing disorder, some doubt may be entertained by those who may have adopted the hastily formed and incorrect dogma that two disorders cannot co-exist in the economy. This may be true in respect of certain febrile diseases, especially those of a specific or exanthematous kind : but in nearly all beside, so very numerous are the exceptions, that the principle becomes quite untenable ; arid, in many cases, even an opposite doctrine may be enforced, particularly | in respect of bilious and nervous disorders. Thus, J when the functions of the stomach are weakened, or those of the liver obstructed, various affec- tions of different organs related to these, either | in function or anatomical connection are apt to supervene, more especially febrile diseases, dis- I orders of the bowels, brain, and lungs. The exhaustion of the powers of life partially con- tinuing during convalescence, also disposes the frame to the invasion of the exciting causes. On this account, convalescence ought always to be watched by the ordinary medical attendant, who, if not allowed to continue his aid for this purpose, should state his reasons for proffering it; and, if it should be declined, the patient will then have himself only to blame. (See Debi- lity, &c.) 22. t. Amongst the other individual predis- posing causes of disease, I may mention the pregnant and puerperal states, that favour, in a very marked manner, the occurrence of several maladies, which, owing to this connection, have been denominated puerperal, &e. Although these diseases arise chiefly from the predisposition cre- ated by the conditions of the female organs and constitution during these states, yet a great differ- ence exists between them as to their necessary de- 562 DISEASE — Predisposition to — yEtiology. pendence upon these conditions ; for, whilst these staies predispose to the invasion of exciting causes developing disease in all instances, the maladies that result may be either such as are peculiar to them, as adynamic puerperal fever, &c. ; or such as are not necessarily dependent upon, although remarkably favoured by, them, as inflammations of the uterus and peritoneum, uterine haemorrhage, convulsions, mania, &c. During the puerperal state, also, the predisposition to fevers, inflammations, consumption, various nervous affections, rheuma- tism, &c, although less strong than to the preced- ing, yet is greater at this period thau at any other. 23. B. Amongst those predisposing causes which are not peculiar to the individual, but which affect persons individually and occasionally, cer- tain states of the mind deserve the first place.— (a) When the mental energies are depressed by grief, anxiety, disappointment, fear, &c, the pow- ers of life are less able to oppose the debilita- ting causes of disease which invade them from without, and of which nature all the exciting causes of fevers, particularly those which are specific or contagious and miasmal, generally partake in a most marked manner. On the oth- er hand, when the mind is elevated by success, by hope, by confidence, and the other exciting passions, the depressing causes make little or no impression upon the constitution ; and individuals thus circumstanced almost always escape from diseases which readily invade the fearful, the dejected, and the disappointed. There is, per- haps, no circumstance which more certainly dis- poses the system to the operation of the exciting causes of fever, than the fear of being attacked by it; whilst nothing fortifies the constitution more surely than a full confidence that the causes of disease will not take effect. 24. (b) Next in importance to mental depres- sions, is whatever lowers the vital energies, or exhausts and debilitates the body. Under this head, low diet, fatigue, previous illness, excessive secre- tions and discharges, want of sleep, and venereal excesses, may be classed. (See art. Debility.) 25. (c) Dress, even, has a very evident influ- ence in creating a predisposition to disease. Too little clothing, particularly in females, favours the occurrence of difficult and suppressed menstru- ation, pulmonary diseases, and disorders of the bowels. It was remarked, during the French revolution, when it was the fashion to dress clas- sically,— which was almost a state of seminu- dity,and more appropriate to the warmer climates of Athens and Rome than to those of the north of France and this country, — that pulmonary diseases, rheumatism, suppressed menstruation, bowel complaints, catarrhs ; and amongst the children, who were exposed with naked busts and thin clothing, croup and other diseases of the air passages and lungs ; were uncommonly prev- alent. On the other hand, too warm clothing is a source of disease, sometimes even of the same diseases which originate in exposure to cold ; and often renders the frame more susceptible of im- pressions of cold, especially of cold air taken into the lungs. The remarks now offered may be applied to overheated sitting and sleeping apartments, and to warm soft beds and bed- clothing. These relax and weaken the frame, dispose to disorders of the kidneys, urinary and sexual organs, and render the system much more susceptible of injurious impressions from without. A predisposition is thus produced, not only to ca- tarrhs, inflammations, affections of the lungs, and rheumatism, but to irregularity in the menstrual discharge. It has been remarked, that the fe- males in Holland, who generally use very warm clothing, warm apartments, and warm beds, are very subject to excessive menstruation and fluor albus. Females, also, become disposed to various diseases, particularly those affecting the pulmo- nary organs and heart, from wearing very tight- laced and unyielding corsets. Indeed, those dressed in this manner can scarcely call the inter- costal muscles into action, and can breath only by means of the diaphragm. The mechanism of respiration being thus impeded, the requisite changes are not fully produced upon the circu- lating fluid ; and congestion supervenes in the lungs, right side of the heart, and parts situated below the seat of pressure. This cause is espe- cially injurious to females during growth and pregnancy; for the chest should be fully and freely expanded, especially at these periods, in order that the circulation through the lungs and heart may be unimpeded ; and that the blood should experience those changes without inter- ruption, that are required for the developement of the body and of the foetus. The functions, not only of the lungs and heart, but of the liver, stomach, and bowels, are materially in- terrupted, and even these organs themselves are removed from their natural positions in respect of each other, by this cause. This is more re- markably the case as regards the colon, which, by the squeezing together of the hypochondria and lateral regions of the abdomen, is thrown into unnatural duplicatures ; the passage of the faecal matters along it being thereby impeded, and habitual costiveness, with all its consequences, produced. 26. (d) Amongst the most frequent predis- posing causes to disease, is intemperance in food and drink. Too much and too great a variety, particularly of animal food, high-seasoned dishes and soups, rich sauces, the too liberal use of vinous, spirituous, or other exciting liquors, over- load, over-distend, and over-excite the stomach ; dispose it, the liver, and bowels to inflammations and functional and orgauic disease; directly in- duce plethora ; and, when this state is produced, inflammatory complaints in early life, and gout, apoplexy, paralysis, &c. at a more mature age, frequently follow. On the other hand, an un- wholesome, poor, innutritious diet, or food of a fluid or watery consistence, predisposes to dis- eases of debility, by diminishing the powers of life, particularly in the digestive organs, and les- sening the vital resistance to depressing causes. Typhoid or adynamic fevers, dysentery, cuta- neous complaints, verminous diseases, tubercles, scrofula, scurvy, scorbutic dysentery, enlargements and affections of the joints, are common under such circumstances, 127. (e) Excessive secretions and evacuations, although in some instances a disease of them- selves, frequently predispose to further disease. The abuse of remedies which have an evacu- ent operation, excessive perspiration, fluor albus, too long suckling, and venereal excesses, weak- en the powers of life, and expose them to the invasion of exciting causes. DISEASE — Predisposition to — ^Etiology. 563 28. (/) Indolence and too great exertion, both predispose to, and occasion disease ; whilst mod- erate exercise, especially in the open air, increases the energies of the frame. Fatigue generally favours the impression of causes which produce acute affections, as fevers and inflammations; whilst indolence and sedentary occupations dis- pose to chronic maladies, as congestions of the liver and abdominal organs, to corpulency, apo- plexy, hemorrhoidal affections, and derangements characterised by diminished tone of the nervous and vascular systems. 29. (g) Sleep.— The want of this jestorer of the vital energies favours the invasion of fevers, inflammations of the brain, and disordered mani- festations of mind ; whilst too much sleep, and the horizontal posture too long retained, or too fre- quently assumed, predispose to apoplexy, paraly- sis, softening of the brain, inflammation of the cerebrum or of its coverings, and affections of the kidneys. Many, also, of the causes of acute dis- eases make their impression during sleep, when the body is relaxed, and thereby exposed to their invasion. On the other hand, early rising pro- motes both mental and corporeal energy. It has been remarked by the actuaries of Life Insurance Companies, that early rising is, of all habits, the most conducive to longevity ; all long livers being early risers. 30. (h) Due regulation of the temper, the passions, and desires, and a proper conduct of the imagination, are also necessary to resist exciting causes. Indulgence of temper and passion not only predispose to disease, but also frequently di- rectly excite it, particularly in nervous, irritable, and sanguine temperaments. Diseases of the heart, brain, liver, stomach, and bowels, often originate in these sources. Uncontrolled passions of every description occasion numerous functional and structural changes, seated chiefly in the viscera of the large cavities. Moderation in eating and drinking, in sleep, in the indulgence of those ap- petites, feelings passions, and desires which have been implanted in our natures by a wise Provi- dence for our advantage, gratification, social im- provement, and happiness ; an equable state of the mind, with confidence in our powers ; and the pleasant excitement accompanying a well- regulated course of application to business or study ; are the best means of resisting the impres- sions of injurious agents. 31. C. Generalpredisposing Causes.—Of these, the most universal in their operation are certain constitutions of the atmosphere. Besides the variations in the temperature and dryness of the air, its electrical conditions also vary extremely ; but as yet we are not possessed of sufficient data to enable us to state with precision how far these conditions may predispose to, or directly excite, disease, or what particular change iu our bodies result from certain electrical states of the atmo- sphere. But that the electrical conditions, to- gether with a more or less humid state of the air, are connected, in the relation of cause and effect, with the prevalence of disease, is extremely pro- bable, although not satisfactorily demonstrated. Those conditions which predispose to disease are — 1st, temperature ; 2d, humidity ; 3d, these two states conjoined; and, 4th, electrical conditions of this fluid. Two very important subjects, very intimately allied to these, and which act both as predisposing, exciting, and specific causes, viz. endemic and epidemic influences, are consid- ered in separate articles. 32. (a) Temperature has a considerable influ- ence in generating a predisposition to certain diseases. Thus, in low states of atmospheric tem- perature, the functions of respiration are fully and actively performed, especially as respects the blood ; and the diseases observed in such circum- stances are of an inflammatory nature, are seated chiefly in the respiratory organs, and are charac- terised, unless when the reduction of temperature is remarkably great, or the air very moist, by reaction of the powers of life on the causes which excite them. Very warm states of the air impede the changes which the blood undergoes in the lungs ; and, by thereby furnishing abundant ma- terials for the formation of bile, occasion an in- creased secretion of this fluid. Hence bilious diseases are most prevalent during high atmos- pheric temperature. This effect upon the blood is still more marked, if warmth be conjoined with moisture (§ 34.). Under those circumstances, bilious fevers, hepatic diseases, dysentery, diar- rhoea, and cholera prevail. 33. (b)Moisture. — In dry states of the air, changes are fully effected on the blood by respira- tion ; its watery portions are more freely carried off from the exhaling surfaces ; its purity is increased, its congestion and excessive fulness prevented ; and, consequently, the vital energies are promoted ; and the depressing causes of disease, as infectious animal effluvia, and terrestrial exhalations, make much less impression on the system. Disorders occurring in this state of air assume chiefly a phlo- gistic or sthenic character, and affect most fre- quently the organs of respiration and the nervous system. A very moist state of atmosphere causes opposite effects. It fails of producing to the full extent the requisite changes in the blood, and of carrying off the fluids exhaled from the surfaces, especially of the lungs; thereby rendering the powers of life more languid, and the system consequently more open to the invasion of the exciting causes. Less moisture, also, being ex- haled, the elements of biliary secretion, and the watery portion of the blood, become redundant in the vascular system. Hence an abundant secretiou of bile, fevers, affections of the liver, and determination of fluids to the intestinal canal, &c. are promoted. (See art. Climate.) 34. (c) Temperature and moisture conjoined. — That warm and humid states of air are individu- ally active as predisponents of disorder, has been shown ; but it is when they are conjoined, that they are especially injurious. A warm and humid atmosphere dissolves and accumulates the specific causes, such as animal and vegetable effluvia; assists their operation ; and favours a rapid trans- fer of electricity from the earth's surface, and the change in the condition and the accumulation of it in the air resulting therefrom. It has been shown by the experiments of Prout, Fyffe, Allen, and PEPYS,in an artificially increased temperature, and by those I made in an intertropical atmos- phere, that heat remarkably diminishes the changes effected by respiration on the blood ; and these changes are further diminished by warmth asso- ciated with moisture, which, moreover, promotes the passage of positive electricity from the body. And as the researches of Ritter show that the 564 DISEASE —Predisposition to — ^Etiology electricity of the positive pole heightens, whilst that of the negative depresses, the actions of life, the ultimate effect of humid atmospheric warmth, as respects both the state of the circulating fluid and the locomotive electricity of the body, will be to lower the whole circle of vital manifestations, and to dispose to, or even to induce, diseases of a low character — to occasion adynamic, continued, and remittent fevers, or agues of a pernicious and congestive kind, or dysentery, cholera, chronic asthma, diarrhcea, and affections of the liver and spleen. A moist and warm air may, therefore, be stated to be doubly injurious, inasmuch as it is of itself an extremely active predisposing and ex- citing cause, and as it is the means of dissolving vegetable and animal miasms,—of marsh, infec- tious, and pestiferous emanations,—and the ve- hicle or medium in which they act injuriously on the frame. 35. (d) A moderately cold and a dry air in- creases the respiratory actions, and the energies of the system ; proving what is commonly called a bracing atmosphere. Diseases usually assume an acute, sthenic, or phlogistic form ; and the respiratory organs are liable to suffer.—In cold and moist states of air, rheumatism, gout, nerv- ous affections, scrofula, and glandular diseases, intermittent and adynamic fevers, erysipelas, dropsies, anasarca, and chronic disorders and congestions, often prevail, especially in low, ill- ventilated, and marshy places. The positive elec- tricity being rapidly carried off by induction from the body, a salutary stimulus, and one which experiments have shown to be productive of in- creased activity of all the animal functions, may be supposed to be lost. But when the air is very dry, the transit of electricity from the surface of the earth and from the body is impeded ; this fluid accumulating until a moister state of air diminishes its quantity, and changes the re- lation subsisting between the electrical condition of the frame and that of the atmosphere. In very dry and warm states of air diseases less frequently prevail than when it is both warm and moist; and are more frequently characterised by increased vascular action. Inflammatory fevers, inflamma- tions of the brain, liver, and stomach, are then most prevalent. 36. (e) Sol-lunar influence. — Considerable importance has been attached to the influence of the sun and moon in creating a morbid predis- position. Close observation of the relation sub- sisting between the prevalence of fever and dysen- tery, and the full and change of the moon, has apparently established some degree of connection between them in warm climates, particularly in the eastern hemisphere ; but the manner of ex- plaining this circumstance has been by no means satisfactory. Some impute it to a direct lunar- influence ; and adduce in support of their opinion • the fact, that dead animal matter, when ex- posed to the moon's rays, more speedily suffers decomposition than when protected from them. Others, who favour sol-lunar influence, argue that it proceeds from the height of the tides, at full and change of the moon, occasioning the rivers on the coasts to inundate their banks, and to deposit vegeto-animal matter, which is rapidly decomposed, when the water retires and leaves the low ground exposed to the sun's influence. But if the relation subsisting between the preva- lence of disease, and the moon's changes, were bwing to this circumstance, it could hold only m respect of parts situated in the low alluvial coun- tries on the coast, and not in districts inland and much elevated above the level of the sea. This, however, is not the case ; for observation has shown the influence, whatever it may be, to be as powerful in high and inland countries as in dis- tricts on the sea-shore. 37. (/) Light and sunshine.—That the power of the sun's direct and refracted rays, in the pro- duction and removal of disease, is by no means inconsiderable, is proved by their influence on the vegetable and animal kingdoms ; and by the ef- fects which ensue in the economy when they are entirely excluded. These effects have been de- scribed in the articles on the Blood (§ 47.), and Debility (§ 6. c). The vital depression, atten- ded by increased sensibility, mobility, and suscep- tibility to impressions, and the anaemia and gene- ral cachexy, which ultimately result from the protracted exclusion of light, are sufficient proofs of the beneficial influence of the sun's rays upon the frame. But additional and more direct evidence is furnished in the greater activity of the vital functions in spring ; and in the genial excitement of the frame of the aged and debilita- ted, and indeed of both the minds and the bodies of all, by sunshine; light, as ordained and regu- lated by nature, being a salutary stimulus, and necessary to the energetic and healthy perform- ance of all the functions. The exciting and de- pressing effects of the excess and absence of light respectively prove its influence over all the organic and mental manifestations, and consequently its power in predisposing to, and even exciting, dis- ease— the intense or continued action of light inordinately exciting the nervous and vascular systems, and producing disorders of this kind ; its abstraction weakening all the mental and bodily functions, and favouring the occurrence of diseases of debility. It is obvious from this, that light, especially sunshine — and even its abstraction — may be made subservient to the removal of dis- ease, either in its individual capacity, or in associ- ation with a pure, dry, and temperate, or warm air, assisted by suitable exercise, and change of locality ; and that the partial abstraction of one or both of these requisites to the due or energetic performance of the functions, must be ultimately followed by disease, however remote the effect, or numerous the intermediate links in the chain of causation. 38. ii. The exciting Causes.— These have been called occasional by some writers, and direct by others, determining by several, and principal by a few writers. I shall divide this class of causes into—(a) those which are occasional in their operation ; and (b) those which are specific, or whose influence is followed by specific and de- terminate results. The causes already described, dispose the body to the action of those about to be noticed; either by impeding, modifying, or interrupting some one or more of the vital func- tions, or by changing the constitution or organ- ization of the tissues or organs which are the instruments of the functions under the dominion of life. But the predisposing causes may, either by their activity, or by their acting in combination or in close succession, of themselves produce dis- ease, without the aid of any of those which are DISEASE.— Exciting Causes of — ^Etiology. 565 usually termed exciting; the predisposing, being in such cases the true and only exciting, causes. Thus the indulgence of the appetites, fatigue, the depressing passions, moist states of the air, &c.— either alone, or associated with age, or constitu- tion, or habit of body, &c. — are often the only causes to which disease can be traced. On the other hand, the exciting causes frequently produce their effects without the previous operation, as far as we have the means of knowing, of the pre- disposing causes ; and many of them merely predispose the system to the action of others fol- lowing in close succession. 33. 1st. The occasional exciting causes act either — (a) upon the vital functions, or the manifest- ations of life in the various organs and structures; or (6) upon the organization of the part to which they are applied. 40. A. Of the ca'ites which primarily influence the functions.—These will be considered in rela- tion to the organs on which they immediately and chiefly act:—1st, Those which are applied to, and disorder or obstruct the functions of the ex- ternal parts of the body; 2d, Those which make their morbid impression upon the respiratory organs; 3d, Those which act simultaneously upon both the cutaneous and pulmonary surfaces; 4th, Those which act primarily upon the digestive organs; 5th, Those which affect the organs of sense; 6th, and lastly, Those which excite the feelings, passions, and moral emotions, and there- by modify the manifestations of mind, or the func- tions and organization of the body. 41. (a) The causes which injuriously affect the external parts of the frame, either disorder the perspiratory and eliminating functions of the cutaneous surface, or modify the sensibility, or obstruct the actions, of external parts.— a. The perspiratory offices of the s'-cin are disordered by the diversified modes in which its temperature is affected. Heat increases the organic actions of this surface — by exciting the nervous influence, expanding and relaxing the capillaries and ex- haling pores, and, indeed, all the integumentary tissues, by determining thither an augmented circulation, and thereby increasing the vital tur- gescence and excretory functions, — and cold diminishes or entirely arrests all these actions (as shown in the art. Cold); the excessive in- crease or diminution of the cutaneous functions ia a part or hi the whole of the surface, by dis- ordering the bakmce between those performed throughout the frame, exciting diseases which assume varied forms and grades, according to the predisposition of different organs, the state of the system, and the causes which may co-operate with the change of temperature. Whilst insol- ation and unusual warmth in any form — as warm baths, vapour baths, currents of heated air, frictions, &c. — are powerful agents in the production or in the removal of disease, accord- ing to the circumstances in which they are em- ployed, considerable or prolonged cold is equally efficient-in both capacities. But it is more owing to the vicissitudes of temperature — to their rapid alternations—than to any excessive grade of either, that the supervention of disorder is to be imputed. The sudden suppression of a copious perspiration; the partial exposure, also, of certain parts, and the superfluous coverings of others; or the action of currents of cold air upon one part, and of 48 radiant heat on another, as when seated neeu large fires; and wearing unnecessary covering! on the head, whilst the circulation is determined to it by position; are also no mean agents in the production of rheumatic and nervous affections, and inflammations, by deranging both the per- spiratory functions, and the sensibility of the parts thus oppositely acted upon. The influence of too much clothing around the hips and thighs of females, and of too soft and warm beds and couches, in favouring uterine and vaginal dis- charges, and haemorrhoids; and of too little clothing on the same parts, in obstructing the catamenia ; is generally admitted. The want of personal and domestic cleanliness, by allowing the accumulation of sordes upon the cutaneous surface, and the continued irritation of hurtful matters which may have come in contact with it, is a frequent cause of disorder of both its functions and its sensibility, and a common origin of many of the eruptions to which it is liable. 42. p. Obstructions to the free actions of volun- tary parts are often occasioned by the kind or fashion of the coverings which protect them ; and, not infrequently, injurious pressure of parts is superadded. Very thick and unyielding shoes prevent the developement of the muscles of the lower limbs, particularly the gastrocnemii, weak- en the ankle joints, and occasion a shuffling gait. Strait, confined clothes, on young and growing persons, cinctures of any part, and too close or straitly braced breeches, sometimes produce dis- eases of the organs of generation, varicose state of the veins, varicocele, flexures of the spine; and wastings, painful affections and organic changes of the testes. All impediments to free motion and the exercise of our organs are more or less injurious. 43. (b) The respiratory surfaces are affected by several of the causes which act upon the cutane- ous surface. The operation of a warm and moist, or of a cold and humid, air on the lungs, and, through them, upon the whole frame, has already been pointed out. (See § 32—35., and art. Cold.) The specific gravity, also, of the atmosphere has some influence in disease; the diminution of it occasionally producing haemorrhages from mu- nCous surfaces. Exertions of voice or speech, long and loud speaking, running against the wind, and foreign substances floating in the air (as shown in the article on Arts and Em- ployments) are common causes of bronchial and pulmonary affections. The pollen or the odour of vegetables, grass, and flowers, the effluvium of new hay, &c, sometimes give rise to severe attacks of asthma, or that form of it which has recently been termed hay fever. The animal effluvia floating in the warm, moist, aud often stagnant air of assemblies, theatres, camps, ships, hospitals, and crowded gaols, in- dependently of the admixture of any of the specific miasms hereafter to be noticed, change the condition of the organic nervous influence, disorder the secreting functions, contaminate the circulating fluid, and, in this manner, pro- duce effects which are injurious in proportion to their concentration or intensity — generally low or adynamic fevers. Chemical fumes some- times excite bronchitis ; and various simple or compound gases, the air of mines, the exhalations 566 DISEASE —Exciting Causes of — Dietetics — ^Etiology. of privies and sewers, and even of new-painted rooms, are productive of syncope, asphyxy, or even apoplexy, convulsions' and paralysis. In such cases, the diminution of oxygen in the respired air, or the impression made by the fo- reign fumes or gases upon the nerves of the respiratory organs, or both conjoined, impede, obstruct, or arrest the changes produced upon the blood in the lungs, and ultimately terminate in death, preceded by one or more of the above affections. 44. (c) Several of the exciting causes act upon both the external and respiratory surfaces; espe- cially vicissitudes of season, of temperature, and of dryness of the atmosphere, suddenly passing from a cold to a warm air, prevailing winds (see Climate, § 11, 12.), the night or morning air; and numerous circumstances connected with the habitation or locality — especially the exist- ence of the endemic sources of disease in its vicinity — ventilation, temperature, and dryness. The influence of northeast winds in reproducing attacks of ague and rheumatism; of the night and morning air in causing disorders of the mucous surfaces; and of low, damp, ill-ventilated, and crowded habitations, in giving rise to fevers; is well known. 45. (d) On the digestive surfaces and organs.— a. Mode of operation.— The numerous and di- versified substances which are either commonly, occasionally, or accidentally received into these organs, produce their effects in different ways. Those which are injurious from their specific ten- dency, or from excess, as numerous poisonous and medicinal substances; and those which dis- agree, from idiosyncrasy, mode of preparation, or injudicious admixture with others, as various articles of food, drink, and condiment; act in some one of the following modes: — 1st, By irritating the villous surface, or altering its or- ganic actions from the standard of health. 2d, By exciting, depressing, or otherwise modifying the nervous power of these organs; the morbid impres- sion being propagated, in a greater or less degree, to other related organs. 3d, By both these modes of action conjoined. 4th, By the absorption of these substances into the circulating fluids, and by their exciting, depressing, or changing the vital actions, through this channel; the manifestations of life in the organic nervous system, or in the blood itself, or in the cerebro-spinal system, or in secreting and excreting organs, being indivi- dually or conjointly affected in one or other of these ways. And, 5th, both by their primary morbid impression on the digestive villous sur- face and nerves, and their consecutive influence, as stated in the 1st, 2d, and 3d heads; and by their absorption and action, in the manner now assigned.* (See, also, art. Poisoxs.) 46. p. Food and drink. — The full discussion of these topics would comprise the subject of Dietetics ; upon which, however, the scope of this work will not allow me tc enter further than very briefly in connection with the causation of disease. They have already received some atten- * The above classification is in accordance with that published by me in the London Medical Repository for May, 1822, p. 380.; aud was the first that was based upon the absorption of substances into th; circulation, and upon their relative action on the organic nervous, ana cerebro- spinal systems. tion in relation to climate and season (see Cli- mate, § 26.); and to the habits of individuals as to their use (§ 19.). It must be obvious that any article of diet will occasionally be found difficult of digestion, or even injurious, in certain latent and open states of disorder. When ob- structions of any of the viscera, or accumulations of secretions in the biliary organs or in the prima via, already exist, owing to weak action or torpor of any of these parts, very slight aberrations from an accustomed diet, or substances not usually hurtful, may occasion very serious disease. It is also evident that the privation of food and drink; excesses in either, or in both ; and, in this cli- mate, too large a proportion, or the exclusive use, of either animal or vegetable diet; will be productive of correlative ill effects. The exces- sive use of animal food, particularly pork, gives rise to plethora, scrofula, and gout; and the want of vegetables, herbs, and fruits, in sufficient pro- portion to the salted provisions consumed, or an innutritious diet, is productive of scurvy, purpura hsemorrhagica, of an intermediate disorder which may be called land scurvy, and chronic diarrhoea and dysentery. Both flesh and fish are some- times productive of disorder, owing to their being diseased at the time of being killed, to their be- coming tainted subsequently, and to unwholesome ways of preserving them. A poisonous product is occasionally evolved in smoked and dried meats; and shell-fish, chiefly from being imper- fectly boiled, and long kept by the retailers, is often extremely injurious. The plan very gene- rally adopted by the fishmongers of London, of preserving fish — especially turbot, salmon, and, indeed, all the fish that is not sold before even- ing — by means of ice ; a large proportion being frozen, thawed, and frozen and thawed again, as alternately exposed in the day on their stalls, and lodged in the evening and night in the ice- pits, until the cohesion of the fibres is lost, and the flavor dissipated; b most prejudicial to health, particularly during summer and autumn; and is one of the most frequent causes, in Lon- don, of disorders of the stomach and bowels, although overlooked by writers on this class of diseases. Nor does the evil end here ; for all the salmon that becomes tainted from this mode of keeping, is either pickled or smoke-dried, and sold for that prepared iu these modes from the fresh state. Independently, however, of these circumstances, all kinds of fish — some more frequently than others — may occasionally dis- agree, particularly with certain idiosyncrasies, and with weak digestive organs; as lobsters, mussels, &c. Some kinds are even poisonous, especially in warm climates; and others produce disorder from being out of season, as salmon, trout, &c. The injurious action of fish is ex- erted chiefly upon the stomach and bowels; generally in the form of cholera, attended by extreme vital depression; and sometimes by an eruption on the skin. That the poisonous ele- ments are partially absorbed into, and act partly through, the circulation, may be inferred from their effects, and from their peculiar odour being afterwards detected in the cutaneous secretions. The means of preventing and counteracting the ill eflepts of fish are stated in the article Poisons. | Vegetables, even, will also disorder the digestive 1 organs if they be allowed to run to seed, or grow DISEASE — Exciting Causes too far, or if kept too long after they have been removed from the soil. 47. y. Cookery and condiments.—Animal sub- stances become indigestible by being either too much or too little cooked; and vegetable sub- stances, chiefly, by being too little. Fried and baked meats are less digestible than roasted and broiled. Stewed dishes, meats prepared a second i time, and very highly seasoned articles, are all J prejudicial. Fish often disagrees with the sto- mach, from the manner of cooking, and the sauces taken with it; and, of these, butter is one of the worst ingredients. Vinegar, lemon-juice, and salt are the most wholesome condiments; and, if the fish be rich and fat, Cayenne or black spice may be added,—these being amongst the best antidotes to any ill effects it may pro- duce. The livers of fish are generally productive of disorder in weak digestive organs; for, during boiling, all the oil — which is extremely whole- some, and even medicinal, and which might advantageously enter into the composition of the sauce instead of butter — is extracted, and, swim- ming on the surface of the water in which the fish is boiled, is thrown away with it; the part remaining being that only which is generally, but improperly, used. Condiments, excepting by those who have been long habituated to them, are hurtful, unless taken in very small, or at least moderate, quantity. Salt, vinegar, and lemon- juice are the most wholesome under all cir- cumstances. The fact, that salt is necessary to health at all periods of existence, is not easily reconciled with the equally well-established fact, that the protracted use of salted provisions is a principal cause of scurvy, scorbutic dysentery, external sores, ulcers, as well as an evident pre- disposing cause of fevers, inflammations, &c. But it may be presumed that the combination of salt with the animal fibre decomposes it or modifies its effects upon the living system. Besides, salted meat, particularly when it has been long preserved, becomes less nutritious, and more difficult of di- gestion; the ill effects being equally attributable to the deficiency of vegetables, frequently con- joined with bad water, and the depressing passions. 4S. 9. Baked pastes, and pies, tarts, 8fc, and the boiled dough of puddings, are difficult of digestion, especially the former; and should never be taken by dyspeptics. Fruit, when in season, is much more wholesome. But if it be used either previously to being fully ripe, or when it has become over-ripe or stale, and particularly if it be uncooked, disorders of the stomach and bowels are frequently produced by it. New cheese is very injurious when partaken of largely; and nuts, cucumbers, and melons are always indi- gestible, however ripe they may be. A variety of fruits, immediately after a full meal, is also pro- ductive of disorder; the most wholesome being ripe oranges, grapes, strawberries, &c. All pre- served and stimulating articles of dessert merely load the stomach, occasion thirst, and lead to the ingestion of a greater quantity of fluid, and of wine, than is consistent with easy digestion, and with the regular performance of the functions. 49. f. Drink and beverages are also common sources of disease, either from being of improper kind, or used in excessive quantity. The most wholesome wines are port and sherry, after hav- ing been six or eight yean in bottle, and the of—Dietetics — ./Etiology 567 finest and highest flavoured French and Rhenish wines. The constant use, however, of even the best port and sherry occasions vascular plethora, and its consequent ills, unless very active exer- cise be taken. Delicate persons should dilute them with an equal, or one half the quantity of water. Champagne often excites gout: I have observed two or three glasses of it bring on an attack the following day. Malt liquors, although both tonic and nourishing, owing to the hop and extract of malt contained in them, occasion dis- ease when constantly used, from these very cir- cumstances; a plethoric state of the system, obesity, and various contingent diseases, being the result. The most wholesome of this kind of beverage is brisk small beer. Cider and perry are sometimes productive of colicky affections, gastrodynia, indigestion, and diarrhcea, especially if they be taken while the body is perspiring, or in very hot weather. Spruce beer is much more wholesome. Spirituous liquors, particularly those in common use, are most injurious to the frame; and, in the lower classes, are the most frequent causes of, first, functional, and afterwards organic, diseases of the stomach, liver, bowels, and brain, as well as of some other viscera, and of insanity. Coffee and tea, although, upon the whole, whole- some beverages, may be, in some constitutions and states of the system, productive of disorder. A strong infusion of coffee, taken soon after the principal meal, promotes digestion, and counter- acts whatever ill effects the cold and poor wines used on the Continent might otherwise produce. But it is sometimes injurious, from its stimulant properties, in cases of cerebral irritation or ex- citement; and, when taken late in the evening, prevents sleep. The infusions of black or green tea are gently tonic and narcotic; the latter act- ing more energetically upon the cerebro-spinal system than the former. Green tea usually ex- cites the nervous power; and, like coffee, in- creases the activity of the cerebral functions. But, when morbid, vascular, or nervous excite- ment exists, it generally proves an excellent tonic and sedative; procuring sleep, and diminishing both nervous and vascular disorder. In cases of asthenic vascular action, attended by coma or lethargy, I have found it a most valuable re- storative of both vital and cerebral power. In addition to the above, the use of hard or un- wholesome water, and either a high or a very low temperature of tbe ingesta, are often productive of disease. 50. f. The effects of accidental or designed in- gestion of poisonous substances, as well as the means of counteracting and removing them, are considered at another place; and, although in- ■ judicious uses of remedial means are but too fre- quently causes of disease, and of its aggravation, especially the inappropriate use of mercurial pre- parations, of emetics and irritating purgatives, of vascular depletions; of stimulating and heating substances, exhibited with the view of restoring nervous power, or of promoting expectoration, when the increased vascular action from whence it proceeds should be allayed; and of secret re- medies of every description; the nature of the sub- ject precludes further allusion to it at this place. The influence of morbid secretions poured into the digestive tube, and the effects of arresting accus- tomed or salutary evacuations, as increased dis- 568 DISEASE —Exciting Causes of — ^Etiology. charges from the uterine organs, haemorrhoids, &c, or vicarious secretions, without having opened an artificial outlet or produced artificial irritation and discharge, in extending, perpetuat- ing, and aggravating disease, rather than origin- ating it —for morbid states of secretion imply existing disorder — are sufficiently obvious. 51. (e) The causes which act on the organs of sense consist chiefly of the abstraction of the natural stimuli or impressions, and the applica- tion of them in unusually intense forms; the mental phenomena excited through the medium of the senses not falling under this head.— a. Sight may be weakened by prolonged dark- ness, and consequent inaction of the organ; but it is much more commonly injured by the un- usual impression of light, which may so intensely excite and exhaust its sensibility as to destroy its functions. The rays of the sun, and lightning, have produced this effect almost instantaneously; and the light reflected from snow in northern countries, and from the sands of the arid districts of intertropical climates, has frequently occasioned it in a slower but not less effectual manner. Per- sons employed in glass-works, forges, founderies, &c, who frequently subject their eyes to an in- tense light and radiant heat; and those who are occupied on small, very near, or minute objects; are often affected by amaurosis, cataract, and other chronic disorders of the organ. When the sensibility of the eyes is increased by protracted darkness, the admission of even a moderate light often becomes painful and injurious, if it take place suddenly. Of the various colours reflected by the rays of light, white and red are most fatiguing to the sight. — p. Hearing is injured by very loud noises, or detonations, near to the organ: and persons of weak or nervous constitu- tions may even lose this sense by such causes; or experience convulsive seizures, syncope, vio- lent palpitations, or disorder of the digestive and circulating organs. Loud noises are extremely injurious in all cases of cerebral and vascular ' excitement; and in cases of external injury, as well as of internal inflammation. M. Percy states, that he observed the wounded often very sensibly affected by the report of cannon during sieges and battles. — y The sense of touch, and the sensibility of external parts, are acted on by many of the causes already noticed; but often in an imperceptible manner. Numerous external irritants; extremes of temperature, either of the air, or artificially excited, as extensive vesications and burns; violent or protracted excitement of the senses of sight and hearing; or irritations or iujuries of nerves; frequently affect sympatheti- cally the whole frame; and even occasion con- vulsions, spasms, inflammation of the brain and spinal chord, or of their membranes; and, when extremely intense in relation to the vital resist- ance of the sufferer, great depression, and even fatal sinking, of the powers of life. — 9. The sense of smell may be impaired by over-excite- I ment; or by causes acting in this, or in any other way. It is also partly through this sense that various agents invade the system, espe- cially those of a depressing kind, as infectious effluvia. (See art. Infection.) Odours some- times, also, produce syncope, nausea, vomiting, and nervous affections through this medium. — . The sense of taste is least frequently the channel through which exciting causes act: the impression, however, made upon the palate by certain articles are sometimes productive of severe disorder of the digestive organs; and, in the case of the more active narcotics, &c, of dangerous disease of the nervous system. 52. In the foregoing review, those causes which act externally upon, or through the medium of, the organs of sense have been noticed. But there are numerous changes, which are intrinsic, or take place in the organic, nervous, and circulating systems, as well as in the brain and secreting viscera, and which affect these organs in a very remarkable manner. These, however, are rather secondary or pathological causes — or the effects of agents acting primarily upon those or other parts of the frame, which effects become contin- gent or necessary causes of disorders of the or- gans of sense—from altering their condition, or the state of parts necessary to the perfect per- formance of their functions. Thus the senses may be disordered or altogether abolished by disease of the brain, or of their nerves, or by af- fections of the digestive and assimilating viscera. This influence of disease of one viscus or system, upon those anatomically or physiologically re- lated to it, also subsists more or less evidently throughout the frame; the primary affection giving rise to a variety of sympathetic and se- condary disorders, according to the progress it has made, to the circumstances that have influ- enced it in its course, and the predisposition of the individual (§ 21.). 53. (/) On the sentiments and passions.—The circulation of the brain, the action of the heart, and the functions of the digestive and generative organs, are frequently disturbed by causes affect- ing the manifestations of mind. — u. Excessive mental employment; long protracted attention, especially to one subject; over-exertion of indivi- dual powers, without the requisite repose, and the relaxation resulting from an agreeable diver- sity of pursuit; the distraction also occasioned by a number of pressing or abstract topics; can seldom be very long persisted in, without ex- hausting the mental energies, exciting or other- wise disturbing the circulation through the brain, and ultimately inducing either acute or chronic cerebral disease, as phrenitis, delirium, insanity, apoplexy, paralysis, epilepsy, &c; especially if other circumstances concur to excite or over- load the vascular system, and determine the cir- culation to the head, or if the requisite nightly repose be abridged or interrupted. — p. Certain trains of feelings, and particular desires or pas- sions, as rehgious sentiments, affection, love, hatred, revenge, avarice, pride, vanity, &c, may all be carried to that pitch, by being con- stantly and exclusively entertained, as insensibly to pass into monomania, or other forms of insa- nity ; or to occasion ecstasy, catalepsy, convul- sions, or some one of the diseases mentioned above (a) — -/. Various circumstances occa- sioning solicitude, anxiety, distress of mind, sadness, fear, shame, penitence, disappointments and losses of all kinds, the indulgence of grief, and anxious or constant longings after objects of desire or of affection, may not only disorder the mental manifestations in a partial or general manner, but also disturb the functions of the heart, as well as those of digestion and assimi- DISEASE — Specific Causes of—./Etiology. 569 lation. All the depressing emotions of mind have an especial effect upon the circulation, upon the nutrition of the frame, and indeed upon all the functions dependent upon the organic nervous sys- tem; and favour chronic and asthenic diseases of the heart, particularly passive dilatation and en- largement of its cavities, indigestion, and consti- pation; also chlorosis, pulmonary consumption, hysteria, and tubercles, early in life; and hypo- chondriasis, melancholia, chronic diseases of the liver, spleen, and pancreas, and cancerous or other malignant diseases, at mature or advanced ages. — 9. Surprise, fright, terror, anger, and in- dignation, are not infrequently productive of apo- plexy, paralysis, epilepsy, convulsions, syncope, violent palpitations, painful or acute affections of the heart, disorders of the stomach, liver, and bowels, hysteria, abortions, derangement of the uterine functions, and of the manifestations of mind.—e. Great mental excitement, unlooked- for success, the sudden accession of fortune, extreme joy, and all the pleasurable emotions carried to excess, are not infrequent causes of insanity, of phrenitis, epileptic convulsions, hys- teria, and catalepsy.— t. An improper conduct, and an insufficient control, not only of the sen- timents and emotions, but also of the imagination, are amongst the most common causes of disorder in the manifestations of mind, as well as of the other maladies enumerated above (a, p).—»;. Inordinate indulgence of the sexual appetite occasions epilepsy, loss of memory, and mental and corporeal debility, impoteucy, diseases of the testes, prostate gland, and urinary bladder, and affections of the heart and lungs in males; and in females, inflammation of the ovaria and uterus, fluor albus, hysteria, chlorosis, melan- choly, irregular convulsions, organic or scirrhous changes in the uterus, diseases of the ovaria, and sterility, &c. (See art. Age, § 24.)—&. Persons who have been habituated to excessive sexual indulgence, and become altogether con- tinent, are liable to nocturnal emissions, to im- potency, convulsive and other nervous diseases, and to disordered mental manifestations.—t. Numerous acts of volition injudiciously attempted or directed may be productive of the most dan- gerous injuries and disease; as violent muscular efforts, of sprains, aneurisms, haemorrhages, in- flammation and caries of the vertebrae, or inflam- mation of the intervertebral substances. Positions with the head low, or on the back, and especially such as are uneasy or unnatural, too long retained, or too frequently assumed, give rise to cerebral disorder and curvatures of the spine; and encumbered, obstructed, or too rapid and protracted movements, produce injurious acceler- ation of the circulation, exhaustion, with other ill effects. 54. B. The chemical and mechanical causes of disease require little notice here; the former of these having received attention in the articles on Asphyxy,andPoisoss; and the latter on that of Arts andEmployments,os Causes of Disease. —(a) Chemical agents are injurious—1st, by their influence on the functions of the part with which they come in contact, their effects varying with their individual properties; 2d, by the change they produce in the structure itself, either in : combining with it, or otherwise changing its j constitution, so as to render it incapable of its 4S« healthy offices; and, 3d, by totally destroying the nervous and vital influence, and intimate organis- ation of the part.—(6) Of mechanical causes and positions impeding, upon physical principles, the flux or reflux of the circulation and secreted fluids, continued pressure of various grades, and unna- tural ligatures of parts, are the most common, and act slowly, and often insensibly and unremit- tingly. Shocks or concussions of a part or of the whole of the body, or other kinds of external violence, not only occasion the division, fracture, dislocation, bruise, and comminution of external parts, but also the rupture, laceration, haemor- rhage, displacement, vital depression, or extinction of function of internal viscera, as of the urinary bladder, liver, spleen, stomach, and bowels, brain, spinal chord, &c. 55. iii. The Specific Causes of Disease. —Of the causes which may be thus termed, eman- ations from the soil are, perhaps, the most com- mon. — A. The miasmata arising from stagnant water, partially covering the soil, or covered by vegetating substances; from vegetable matter in a state of decomposition; from moist absorbent soils exposed to the sun's rays; from the muddy and foul bottoms of lakes, marshes, and lagoons, or the mar- shy banks of rivers and canals; and from low grounds which have been partially inundated by the oceanor byrivers;are productive of agues, enlarge- ments of the spleen, of the liver, and even of all the glands, rheumatism, catarrh, &c, in cold or temperate climates; and, in addition to these, of I remittents, bilious and gastric fevers, dysentery, cholera, diarrhcea, and hepatitis, in warm climates and seasons, according to the predisposition of the patient, and the circumstances which have aided the action of the efficient cause on the system. 56. B. When dead animal matters or exuviae mix with vegetable substances, and putrefy along with them, in a warm and moist air, the efflu- vium assumes a more noxious form, especially if the air stagnates in the vicinity of its source; and it becomes more certainly productive of dis- ease than that which proceeds from the decom- | position of vegetable matter only; the effects produced by it being often of a more adynamic [ or malignant character. In warm countries, the localities enumerated above abound with dead animal bodies, and the exuviae of immense swarms of insects; and hence may be inferred the reason wherefore terrestrial emanations in these climates I give rise to more severe forms of intermittent and remittent fevers, depress more remarkably the vital powers, derange more the vascular system, ! and more sensibly affect the blood and the secre- 1 tions, than the miasmata exhaled from similar places in northern latitudes. The water of low, moist, and marshy places is also productive of various maladies, particularly of dysentery, chro- nic diarrhcea, diseases of the spleen, Guinea-worm, &c. These causes and effects, with what is at present known of their operation, are more fully discussed in the arts. Endemic Influence, and Fevers. 57. C. Emanations from animal matter only', the air being in other respects uncontaminated, or frequently renewed, are seldom productive of any serious maladies. But when they burst forth suddenly, in a close and moist air, the effects are sometimes most pernicious. It has been recorded, that fevers of a very malignant kind have attacked 570 DISEASE—Specific Causes of —^Etiology. persons who have opened a grave and exposed the body whilst undergoing decomposition, the efflu- vium having instantly produced a sensible influ- ence upon the frame. The effects of air accumu- lated in sewers, privies, &c, are shown in the article on Asphyxy. 58. The particular elastic fluids which are evolved from the foregoing sources have not been satisfactorily demonstrated by analysis. They seem, however, to consist of an admixture of va- rious gases, in very variable proportions, partic- ularly sulphuretted hydrogen gas, and sulphuro- carburetted hydrogen, with azote, and aqueous vapour, holding the subtiler particles of decom- posed animal and vegetable matters in solution; which particles most probably make the most in- jurious impressions on the frame, and are the actual causes of the consequent disease. 59. D. The various exhalations and secretions formed in the course of disease are most common and important causes. These consist either en- tirely of insensible emanations from the bodies of persons affected by the exanthematous and spe- cific fevers, &c. (infectious); or altogether of a consistent and palpable fluid formed on the mor- bid surface of the diseased body or part, as the itch, lues venerea, &c. (contagious). Many of the maladies which spring from specific causes, propagate themselves, both by impalpable or in- visible emanations from the body floating in the surrounding air, and by the contact of a consistent fluid or virus formed in the diseased part, with a part of an unaffected body rendered capable of being affected by it. Such is the case with small-pox and plague (both infectious and con- tagious.) Maladies which are produced by the contact of a consistent fluid secreted by a diseas- ed part, may be propagated artificially, or by inoculation, although not in every instance where it is attempted. Those, however, which do not form upon some part of the chief seat of disease a consistent secretion, capable of being artificially inserted in a healthy body, may nevertheless be conveyed from one person to another, by bring- ing substances capable of absorbing and retaining for a time the emanations given out from the dis- eased body, as frequently demonstrated by typhus and scarlet fevers, &c; and all those which j are propagated by contact, or by a palpable fluid, also, may be disseminated in a similar way. The substances thus imbibing and conveying the invisible or infectious emanations, as well as the palpable and contagious virus or consistent secre- tions, have been called fomites—if a single sub- stance has been the vehicle, fomes. Of~all the various materials which may thus become the medium of transmitting infectious diseases, animal productions, particularly woollen and hairy sub- stances—manufactured or unmanufactured—furs and feathers, bedding and body-clothes, have the greatest disposition to imbibe the morbid efflu- vium, and to retain it the longest. It seems as if animal emanations were attracted and retained most strongly by substances belonging to the same kingdom. Next to these, cotton, flax, linen, ' and other substances of a soft and porous texture, are most likely to convey morbid effluvia. In respect of the diseases which are really infectious or contagious, or which proceed merely from terrestrial emanations, great difference of opinion exists, and has long existed. Many fallacies con- nected with the use of the terms in dispute, much misapprehension and ignorance, great prejudice, and unbecoming acrimony, have characterised the controversies which have arisen on this sub- ject. The topics, however, connected with it, both essentially and collaterally, are fully dis- cussed in the articles on Fevers—Causes of; and Infection;—and in those on the diseases, respecting the nature of which difference of opin- ion has existed. 60. E. Mode of action of specific causes.— On this subject, a very general remark merely may be hazarded at this place. Those specific causes which are suspended in the atmosphere or dissolved in the moisture it contains, and in- haled into the respiratory passages, seem to make their first impression on the nerves supplying those parts; the organic nervous system being chiefly affected. That this is the case in respect of marsh miasmata, and other terrestrial emana- tions, is indicated by the periodicity—the intervals the recurrences or paroxysms, the exacerbations, and the terminations, of the various diseases re- ferrible to these sources. If the circulating fluid were early and chiefly affected by them, as some believe, morbid action would take place more rapidly, and assume a more malignant and contin- ued form; for, as soon as the blood becomes af- fected, complete remissions are never detected; whereas all affections of the nervous system, es- pecially those of a functional kind, are charac- terised by remissions and exacerbations; or by intermissions and regular paroxysms. In ad- vanced stages, even, of those maladies, particu- larly after the various secreting and depurative functions have been disordered, the circulating fluid probably becomes changed, although not in a very remarkable manner; the chief morbid condition, however, still existing in the organic nervous system. When the miasms floating in the air consist principally or altogether of animal emanations—proceeding either from animal mat- ter in a state of decomposition, or from persons af- fected by adynamic or specific forms of disease— not only may the first impression be made upon the organic nervous system, but the blood itself may also be early contaminated, although not at first in a sensible manner; for it is not unreasonable to infer, that the fluid emanations from the bodies of the diseased, and dissolved or floating in the respired air, may pass into the blood along with those constituents of the air which partially enter it, and in this way induce a similar disease of the whole frame, owing to the universal diffusion of this fluid, and the very intimate connection sub- sisting between it and the organic nervous sys- tem, even before the changes effected in it have become manifest to our imperfect senses. 61. iv. The determining or consecutive Causes of Diseases require little observation, fu rther than that the practitioner should not overlook the circumstance, that the exciting causes, whether common or specific, will frequently fail of being followed by any marked effect, when the system is in due health at the time of exposure to them, and is not subjected for some time afterwards to various additional influences or agents, particu- larly such as produce a depressing or debilitating impression. Thus, a person who has been exposed to emanations from the subjects of typhus fever, or from marshy grounds, &c, may experience no ail- DISEASE — General Doctrine of—Pathogeny. 571 ment, until a change of weather— from dry to moist, &c.—or depressing mental impressions, or cold and fatigue, or venereal excesses, or, in short, any debilitating influence, occur to aid its oper- ation and determine its action; and, if no such consecutive causes aid the principal or specific cause, in a few days from the exposure to it, disease will often not appear. I have frequently seen this exemplified in a very striking manner: one instance on a large scale will be sufficient. Between twenty and thirty persons were exposed all night, without cover, to the air of one of the most fatal sources of miasmata furnished by a warm climate, during the unhealthy season, but were soon afterwards removed to sea—far from any further exposure to this specific cause. They continued well for six or seven days, when about half their number experienced great fatigue. All these were nearly simultaneously — on the fol- lowing day—seized with remittent fever; whilst those who had not been subjected to this conse- cutive cause, with the exception of two, who were not attacked till several days subsequently, entirely escaped, although all had been equally exposed to the specific cause of that form of fever. Further illustrations from my experience in dif- ferent climates, and of various diseases, might be adduced; but the simple statement of the above fact is sufficient. The practical importance of it, however, should not be overlooked; for it shows —what I have frequently believed has been suc- cessfully practised — namely, that a person who has been subjected to the impression of a specific or any other exciting cause, may escape its effects, if he immediately fortify the system against it, and avoid exposure, for some time subsequently, to all other injurious agents, especially those which lower the vital energies of the frame. Persons even who experience the sensations more immediately caused by exciting agents of a spe- cific kind, as infectious emanations, will often escape by observing this precaution, and having recourse to a restorative regimen, with the usual means of promoting all the secreting and excre- ting functions of the frame, as shown in the art. Fever — Prophylactic Means. 62. It is unnecessary to enumerate the causes which most commonly come in aid of the exciting agents of disease. They comprise nearly all those already adduced as predisposing the system to, as well as occasionally exciting, morbid action; particularly such as depress vital power, by their specific properties and immediate impression; the abstraction of requisite or accustomed stimuli, as of warmth, food, &c. ; whatever impedes the functions of respiration, digestion, assimilation, and excretion; all weakening discharges; de- pressing affections of mind, particularly fear of being affected by the cause to which the person was exposed; and all circumstances in any way deranging the accustomed tenor of the mind, and habits of life. 63. III. General Doctrineof Disease, or Pathogeny (from ra.V, disease, and yerrS-, I gender, or produce).—An examination of the systems of medicine proposed since the revival of learning in Europe, or even of those advanced in modern times, would occupy more of my limits than I could devote to the subject. I shall, therefore, proceed at once to the developement of those general views of disease, which observ- ation and reflection have suggested to me, and convinced me to be of importance, not only in estimating aright the exact state of the more com- mon specific maladies, but in forming safe opin- ions respecting those more anomalous or com- plicated affections, which frequently present themselves to the practitioner. 64. I have already contended ( § 7.), that, with few exceptions, which have been particular- ised, the causes of disease first modify the mani- festations oi life in some one or more of the sys- tems and organs with which it is allied; or, in other words, first disorder the functions with which they have a direct relation; and that, after a period of longer or shorter duration, the disorder of function becomes a cause of further disorder in related or associated organs, and ultimately, if circumstances obtain hereafter to be noticed, of change of structure, either in the primary seat of disorder, or in that consecutively affected. From this, and what has been already stated, it will ap- pear that a great proportion—nay, all—of those disorders of internal parts, which have been viewed as intrinsic predisposing and exciting causes of disease, are, in truth, pathological conditions, or existing states of disease, induced by some one or more of the causes specified above, and ready to produce further disease, or to lead on to a salutary change, according as the existing state of vital power or resistance, and the influ- ences or agents acting on it, may determine the procession of phenomena, or incline the balance. These primary or early changes, or morbid con- ditions, may very aptly be termed secondary or pathological causes, when they give rise to ulterior change either of function or structure; but they are so diversified, that but little notice can be taken of them here, beyond what is necessary to the consideration of general principles; their differ- ent forms being more intimately viewed in the ar- ticles on specific diseases. It may, however, be remarked that they often exist in latent, or almost imperceptible, states, and predispose the frame to the invasion of causes to which it otherwise might have been exposed with impunity. 65. The great fault of all systems of pathology, down even to the most recent, lias been their confined or narrow principles, and consequently their inadequacy to the explanation of all the states of morbid action constantly occurring. Brown and his followers admitted but two modi- fications of the vital manifestations from the nor- mal state, viz. depression and excitement, whilst he substituted an inappropriate and single term as a sign for those manifestations, which are as obviously and frequently changed in kind as in degree. Dr. Parry referred the chief states of disease to the vascular system, and to changes in its states of action, without sufficient reference to the nervous system, as controlling and even caus- ing these changes, especially to the organic nerv- ous system, with which the vascular is so inti- mately connected; whilst his contemporaries, who considered that disease originates in the nerv- ous, and affects the vascular, system consecu- tively, viewed the cerebro-spinal axis, and its various prolongations in the form of nerves of sensation and volition, as the parts primarily im- pressed. Considering, however, as stated in the article en Debility ( § 13.), that the intimate association of the organic nervous system with 572 DISEASE —General Doctrinx of — Pathogeny. the vascular system throughout the frame, and particularly in vital, secreting, and assimilating viscera, fulfils important objects,—that these systems are the chief factors of life in the various structures and organs, which, however, modify its manifestations, giving rise thereby to specific manifestations of this endowment, according to the nature of their superadded organisation, so that the liver secretes bile and not urine, the pancreas its peculiar secretion and no other, the kidneys urine, &c. —I believe that the causes of disease commonly act directly upon one or both of these systems, most frequently on the former; and generally on their numerous ramifications in one or more of those organs or surfaces, with which the exciting and other causes are more immediately related, and with which they are brought iu connection from their nature and pro- perties. Thus, those causes which are applied to the respiratory surfaces, primarily affect the organic nerves distributed to them, and the blood- vessels of the lungs, and in some cases the blood itself; and those which are received into the di- gestive organs, make their impression on the nerves supplying them, thereby modifying their vital man- ifestations, as well as the functions of related or associated viscera, according to the properties of the individual agents. Having pointed out the in- timate relation of the exciting and other causes to the organs on which they chiefly act, and having here and at preceding places noticed the particu- lar system on which they seem to exert their primary impression, it becomes requisite next to inquire into the nature of that impression, or early disorder, and afterwards to consider the changes which consecutively accrue, and the means which nature employs to arrest their progress or to give them a salutary tendency. 66. i. Of the principal States of Mor- bid Action.— In considering the earliest aberra- tions from the healthy state following the impres- sion of morbid agents, without especial reference to the system or organs on which they directly act, we are particularly struck with their very diversified nature ; and, upon an intimate view of the numerous shades of difference, often evanescent or inappreciable, between effects ap parently similar, we necessarily arrive at the conclusion, that, however multiplied the various grades of action or vital manifestation may be, some other differences than such as are purely dynamic exist; and that the changes may also be of an anomalous or cachectic kind, — tnat the vital manifestations in the various organs may not merely present simple changes of degree, | but also complicated alterations of kind, — that vital action may not only be depressed and excited, but also changed in other respects, or vitiated, as well as at the same time either de- pressed or excited. Sufficient proof of the above positions will immediately suggest itself to the practitioner, when he considers the dif- ferent states of action that may be even artifi- cially produced by the ingestion of different stimuli, the grades of whose action may be very nearly the same; or when he views the very nu- merous modifications in degree, form, and kind, in which either vital depression or excitement as- sumes, even in affections of the same system or organ. He will, moreover, recollect that nu- merous maladies have come before him, in which the least distinctive characters were those result- ing merely from grades of action; that the most prominent features, whether pathognomonic or diagnostic, had no reference to degree, but to form or kind; and that many of these were of the utmost importance in the recognition of the actual pathological condition, and as bases for therapeutical indications, however difficult it might be to describe or explain them, or to convey such an idea of them as he had himself formed, and successfully applied to practice. Indeed, every one must have remarked, that numerous phenomena, either cognisable to the senses of the observer, or merely connected with the sensations of the patient, indicate rather a change in the condition of life, a vitiation of its properties and manifestations, than any grade either of its depression or excitement. If we take the common symptom of pain, as remarked by Dr. Pring, we have no evidence that it is more intimately allied to increased, than to di- minished, vital action. In imputing it to altered sensibility, we in fact imply that the alteration is not altogether one of grade merely; indeed, a careful examination of related phenomena will show that the most intense states of pain are more commonly connected with lowered than with exalted action. As respects, therefore, numerous changes in particular functions and organs, as well as in the whole body, aud its general manifestations, it may be inferred, that the condition or properties of life, and conse- quently of vital action, may be altered very variously, otherwise than in degree; and that, as intermediate grades of action or vital manifest- ation are ■ innumerable, and admit only of an * arbitrary estimation, so are the modifications or j alterations of it, in kind or condition, equally diversified, — merely the more prominent features admitting of recognition by our imperfect powers of sense, and intellection. 67. 1st. Of the Dynamic States of Vital Manifestation.—Grades of action must neces- sarily be infinite, between the lowest consistent with life, and the highest to which excitement can be carried without passing instantly into complete exhaustion. They have been very generally divided into two classes or divisions, namely, those below, and those above, the medium grade of health; the former having the generic ap- pellations of debility, asthenia, adynamia, and frequently of exhaustion when occurring conse- cutively, applied to them; the latter that of excite- ment, hypersthenia, sthenic or increased action, and often of reaction when secondary or indirect. 68. A. Debility, in its various conditions,— primary, secondary, and complicated; as well as its special manifestations and effects in the dif- ferent systems, tissues, and organs; was fully dis- cussed in an article devoted to the subject; where also its pathological relations — its associations, consequences, and terminations, with its practical bearings, were considered at length. I there- fore proceed to give a succinct account of that state of vital action or manifestation which seems to mount above the standard of health; and which presents various modifications, and produces diversified effects, not only according to its cause, and the system or viscus primarily affected, but also as it may appear primarily or consecutively. DISEASE — General Doctrine of — Pathogeny. 573 69. -B. Of excitement and reaction. — No circumstance has tended more to prevent the ac- quisition of sound principles in pathology than the terms introduced by Brown and his fol- lowers, and the meaning attached to them. In- deed, it was a matter of no small difficulty to arrive at a precise idea of what meaning they did convey; for a single word was in itself an hypothesis; and "excitability"—accumulated, exhausted, &c.—"sensibility," "susceptibility," &c. were made to perform more than actually falls to their lot. As, however, these terms are frequently employed in medicine, and cannot now be conveniently discarded, it will be as well to state the idea that should be attached to them. Sensibility is the faculty of receiving im- pressions, and of being conscious of them. Ex- citability, the power of being excited by stimuli or irritants, whether consciousness attend the act or not; consciousness generally follow- ing their application to organs of sensation and volition, or of animal life; but not when applied to those of involuntary motion, or of vegetative life, unless the excitation be carried to a great height. Susceptibility is the power not only of receiving impressions, but of being affected by them, whether the agents be physical or moral, and whatever may be their mode of operation; consciousness either attending or not attending the act, according to the nature of the agent, and the organ it affects. Here it will be per- ceived, that sensibility implies a certain faculty; excitability the power of acting only in one direc- tion; and susceptibility of being affected in every way, according to the nature of the cause; and that the meanings are the same, whether these terms be applied to a single organ or to the whole frame; they representing intimately allied manifestations of life in organized parts. The states, moreover, which these terms represent, are variously modified in different persons, ac- cording to temperament and constitution; but they are still more remarkably altered by the causes enumerated above, as well as by the suc- cessive changes characterising diseases; and hence they become important signs of the condi- tion of vital power, and of the progress of func- tional and organic change. When existing in a very manifest or extreme degree, they are of themselves important pathological states, and in this respect they deserve notice. 70. Sensibility, excitability, and susceptibility are great or especially prominent in delicate, de- bilitated, nervous, and irritable persons, and are morbidly increased by whatever lowers the general amount of vital power, if the functions of the brain be not impeded, or by excited action in any part of the cerebro-spinal axis not at- tended by pressure. They are much less lively in the robust, lymphatic, and phlegmatic constitu- tions; and are more or less diminished in congestive diseases, particularly those of the brain; in many cases of vital exhaustion, when the blood be- comes contaminated; or when pressure takes place in any part of the cerebro-spinal centres or prolongations. They are likewise temporarily or permanently impaired by the intense, frequent, or continued impression or action of the same impressions; and are restored or heightened by the abstraction of those which are of a lively or intense kind. Although excitability is easily and quickly roused in the delicate and nervous frame, and in states of simple debility, as specified above, yet is it more rapidly exhausted or alto- gether extinguished; whilst, on the other hand, it is much less readily brought into action in the robust; but when once roused, it is either more energetic or longer sustained than in the debili- tated. In these states of disease, which I have denominated secondary and complicated debility, and especially when the cerebro-spinal centres are congested or pressed upon, or when the cir- culating fluid becomes contaminated, the ex- citability is either much diminished or altogether lost,—chiefly, however, as respects voluntary organs, when the nervous system of animal life I is affected; involuntary parts still admitting of excitation, although not so readily as in health. Susceptibility, even more remarkably than the two other powers, is increased by debility and novelty of impression, and diminished by a robust and due manifestation of vital power; by a repe- tition of the same effect, whether it be stimulant or depriment, unless each succeeding application of the same agent be made before that of its antecedent had altogether ceased; as evinced by both the causes of disease and the operation of stimulating and narcotic remedies. The com- plete manner in which the susceptibility to be affected by certain causes of disease is destroyed by their full and adequate action, is shown by several of the specific agents. 71. Excitement may be of two kinds, accord- ing to the manner of its occurrence: it may di- rectly follow the impression of the exciting or irritating cause, in which case it is primary or direct; or it may follow as a more or less remote effect of agents which lower the action either of a part or of the frame throughout, when it con- stitutes what is called secondary, or reaction, as in the case of the vascular excitement following the application of severe cold to a part of or the whole external surfaces. It is necessary to dis- tinguish between these two grand conditions or manifestations of excitement; for the secondary, or that following indirectly the impression of lowering or sedative agents, may be variously modified throughout by the nature of the primary impression, and its mode of action. Hence one cause for the distinction here made. There are, besides, numerous other modifications of excite- ment, whether primary or secondary, referrible to the nature of the agent, and the parts of the body on which they have directly acted. The excitement caused by mental emotions is different in its progress, duration, and consequences, from that following the ingestion of spirituous or other stimuli; and this latter, and indeed both, are different from the increased action following sympathetically the irritation of some organ or viscus. In the first, the cerebro-nervous and vascular systems are simply excited, the excite- ment terminating in slight exhaustion, unless some part has been injured during its contin- uance. In the second, these systems nr-e more than simply excited. A more manifest febrile state continues for sometime subsequently, with concomitant lesion of the digestive functions or viscera, owing to the passage of a portion of the morbid agent into the circulation, and to the more immediate lesion experienced by the parts on which it made its primary impression. hi 49 574 DISEASE—General Doctrine of—Pathogeny. the third, the excitement is more especially ex- pressed in the organic nervous and vascular systems—the chief factors of life — owing to its extension to the whole of these systems, from the part in which it originated, and still exists: hence its duration depends upon the primary lesion, and there is, in addition to the general or sympathetic excitement, disordered function of the part primarily affected, as well as of those more intimately allied to it. Even from what has now been stated will appear the im- portance, in pathological and therapeutical points of view, of instituting a comprehensive analysis of those states of vital action to which the term excitement has been applied, and which bears a very wide and often indefinite signification. 72. (a) Primary or direct excitement is one of the most frequent effects produced by the agents which surround the body. It may pro- ceed from such only as are external to the frame, and to the part which it excites, or from such as are internal or intrinsic. Its phenomena and con- i sequences vary as it arises from causes acting chiefly upon the organic nervous and vascular systems, and their immediately related organs— upon the organs and functions of organic life— and affecting them principally; or from such as act primarily upon the cerebro-spinal system, and organs of animal life, as those of sensation, re- flection, volition, contractility, &c. But the modifications which spring from other sources, especially from the properties of the agent, the intensity of its operation, and the number of parts affected by it, are too numerous for a super- ficial view, even if the knowledge requisite to the attempt were attained. I must therefore content myself with noticing merely a few of the more prominent features of this condition of life. 73. a. Excitement of the systems and organs of vegetative life gives rise to various changes and phenomena, according to the nature of the im- pression, and its intensity.— Gentle excitation of the digestive canal increases the tone or in- sensible contractility not only of it, but also of all the circulating system, of the hollow viscera, and of fibrous or muscular parts. If the stimulus be considerably greater, either the same effect is, produced, or the excitement is concentrated in the digestive viscera, and proportionately with- drawn from other parts. If the excitement be still greater, and be of a kind that irritates the villous surface, the secretions of this surface are augmented, and the muscular coats of the canal roused to more or less energetic action, followed by the excretion of their contents. 74. Excitement of the vascular system is ge- nerally a consequence of stimuli applied to the digestive surface, of irritation of any kind affecting the tissues, of local inflammation, of stimulating substances conveyed into the current of the cir- culation, of muscular exertion, and of the lively mental emotions, directly increasing the heart's action. The grade, duration, and effects of ex- citement originating in this system, vary with the cause and the state of the body at the time. Its gentlest, and, at the same time, most permanent, form is caused by the action of a pure, dry, and temperate atmosphere on the blood circulating in the lungs; whilst the most tumultuous and the most injurious, as respects its effects on the heart and blood-vessels, on the blood itself, and on the functions of vital organs, is that produced by in- ordinate or continued muscular exertion; and by the absorption of various stimulating and irri- tating substances into the blood. Violent exer- cise affects the crasis of the circulating fluid (see Blood, § 134.), causes its irruption through the capillar}' canals of soft and yielding tissues, as the mucous surfaces and the parenchyma of the viscera, induces inflammation of the heart and arteries, and excites similar disease in predisposed organs. Irritating or exciting substances con- veyed into the blood, inflame the internal surface of the heart and arteries, alter the condition of this fluid, occasion various acute and chronic dis- eases of the vessels (seearts. Arteries,Heart, and Veins), and often severely affect the functions of secreting and excreting viscera, inordinately exciting or inflaming those depurative organs which carry them out of the system. 75. The portal circulation, and the liver, to which it is distributed, may be especially ex- cited, owing to the quantity of stimulating, morbid, effete, or foreign matters carried into, or generated in, the blood which is returned from the digestive canal and other abdominal viscera. These may not only inflame the portal vessels, but also the substance of the liver; or, when the materials or elements in these vessels are of a less irritating kind, may give rise to morbidly in- creased secretion of bile, or to various organic changes and adventitious formations in this viscus. 76. The absorbent system is seldom or never co-existently excited with the arterial system. Indeed, inordinately increased vascular action is generally attended by a proportionate inactivity of the absorbents — both lymphatic and lacteal. Whilst it is frequently observable that a weak action of the arterial is accompanied with great activity of the absorbent system. It would seem as if diminished organic action, or that state re- sulting from an insufficient exertion of the organic nervous influence on the arterial and capillary systems — the chief source of nutrition, struc- tural cohesion, and other vital manifestations — leaves, in consequence of the animal molecules being then held together by a weaker attraction than in an opposite state of this influence, a greater proportion of effete materials, by which the absorbent vessels are excited to increased action. 77. Excitement of involuntary muscular parts is characterised by spasmodic contraction of either a permanent or alternating clonic kind — or rather of the various intermediate states between sthenic and asthenic, as marking the extremes — and is generally occasioned by irritants of the surface covering the hollow mus- cles, and more rarely by direct excitation of the nerves supplying them, and by morbid states of the blood, affecting either them or the nerves supplying them. The asthenic or clonic form of spasm is most commonly associated with exhausted vital power or an impure state of the circulat- ing and secreted fluids, the excitability of these structures being more easily acted upon in weak than in robust frames; and hence, when in action, is more rarely conjoined with excitation than with debility of other organs. It would seem that, in most spasmodic disorders, the excitation necessary to this state of action consists in the concentration of an undue proportion of vital I power in the nerves supplying the affected muscles, DISEASE —General D( and in the muscles themselves, and a proportion- ate abstraction of it from other parts; and that when the excitability of an unaffected structure or viscus is energetically roused, the pre-existing morbid excitement will be derived from, or sub- side in, the parts in which it was seated. 78. The excitement of secreting viscera and glands presents various modifications and grades, according to the cause which induced it, and the elementary system especially affected. If the organic nerves supplying them be chiefly ex- cited, the special functions they perform will be augmented—their secretions will be abundant. In this case the excitement will be more par- ticularly limited to the organs whose excitability has been acted upon; the morbid condition con- sisting chiefly of a concentration of vital mani- festation or action in them and derivation of it from other viscera, thus occasioning one of the forms of Debility specified in that article (§8, 9.), the increased secretion generally pre- venting the occurrence of febrile commotion or acute sympathetic disorder, unless it be carried very far. But when the excitement is seated principally in the blood-vessels, and assumes the form of inflammation, the specific function of the secreting surface or organ will be variously al- tered; the fluid elaborated, in this case, by a secreting surface, being either increased or quite changed from the natural state, or both, accord- ing to the degree and form of the excited vascular action with which it is affected; and that secreted by glandular structures being also either much altered, diminished, or entirely suppressed, as in cases of inflammation of the kidneys, salivary glands, &c.; this form of excitement not giving rise to the state of vital concentration observed in respect of the former, but frequently to general or sympathetic febrile commotion. Excitement of secreting viscera, then, assumes two forms, viz. that affecting chiefly the organic nerves—the excitement of irritation, which is always attended by augmented secretion, and increased deter- mination of the circulation to the part thus affect- ed, but not necessarily with true inflammation, although this may follow; and that affecting the arteries and capillaries—the excitement of inflammation, which is accompanied with alter- ed secretion, always in kind and frequently in quantity, — the quantity being often increased in mucous surfaces, and remarkably diminished from glandular organs. 79. The excitement of the generative organs may proceed from the accumulation and irri- tation of their proper secretions, from mental emotions, and from the excitation of adjoining and related parts, as when the rectum or urinary bladder is stimulated. It is, more especially at its commencement, a purely nervous change; the nerves of organic life which chiefly supply these organs being excited, either through the medium of the brain and sensorium, or in a direct manner, and as above stated. There is no part of the economy which furnishes so evident a proof as this does of the influence of the organic nerves upon the local or general circulation; their excitation being here shown to be followed, unless the susceptibility and excitability be en- tirely exhausted, by increased determination, vascular action, and vital expansion of the tis- sues; irritation of this class of nerves evidently ictrine of — Pathogeny. 575 j determining also in other parts of the body, par- ticularly in mucous, glandular, and cellular struc- tures, as well as in these organs, increased flux J of blood, and occasioning the turgidity or vital j expansion of the vascular canals running be- tween the extremities of the arteries and the radicles of the veins. The influence of sexual excitement upon all the other functions, espe- cially at the period of puberty, and subsequently; its sympathetic action on the rest of the nervous system giving rise to various disorders, particular- ly to the numerous forms of hysteria, anomalous convulsions, epilepsy, catalepsy, &c; and its more direct operation in producing menorrhagia, fluor albus, inflammatory and organic changes of the ovaria and uterus, besides other disorders in both sexes, more especially referrible to pre- mature, too frequently repeated, or to excessive stimulation, and consequent exhaustion of the ex- citability of those organs; are circumstances fa- miliar to the practitioner. 80. p. Excitement of the organs of animal life may arise from intrinsic or organic changes, as from the condition of the organic nerves and ves- sels distributed to them, or of the blood itself; or from causes affecting the instruments of sensation, the general sensibility of the frame, or any of the mental manifestations; or from those which excite to mental or physical exertion. Intrinsic changes may occur in the organic nerves and vessels, influencing the circulation through the brain, without any very obvious cause; .and these may be such as will excite not only this part, but all others depending upon it for their functions. It is more than probable, that with the brain, as with other viscera, the excitation may be seated chiefly in the organic nerves distributed to it, and hence assume more of an irritative state, or of an exal- tation of function, without any particular lesion, as when it is simply excited by vinous or spirituous liquors: or the excitement may extend to, and principally affect, the blood-vessels; giving rise, I according to its degree, to certain states of in- flammatory action, and to general febrile com- motion, with more or less lesion of function. It is almost unnecessary to observe that either of those forms of excitement, related as now ex- [ plained, or both of them cofitaneously, may ori- ginate in the exercise of those faculties, of which this organ is the instrument under the endowment of life. It often falls to the physician to trace the progress of excitement in relation to the brain, from the lively exercise of function characterising talent and genius, into exaltations, approaching to morbid, of one or more of the mental manifest- ations; and next, into inflammatory action or mania; and lastly, into a state indicating mental collapse, or structural change. The influence, par- ticularly in susceptible persons, of lively or of vio- lent impressions upon the instruments of sensation, in exciting the nervous centres, with which these instruments are in constant communication, is shown, not only by the effects of loud noises, and of a strong light, but also by violent or painful stimulation of any portion of the sentient system distributed throughout the frame. The sympa- thetic operation of external injuries, of extensive burns or scalds, of long-sustained or suppressed pain and sufferings, in exciting an irritative state of the cerebro-spinal axis and its membranes, in increasing their vascularity, and even in giving 576 DISEASE —General Doctrine of—Pathogeny. rise to effusion, with the related phenomena of delirium tremefaciens, mania, general febrile action, or convulsions, is not the less tme or im- portant, from its being overlooked, and the exact seat and nature of the consecutive suffering, as well as the more immediate cause of death, being misunderstood. 81. Excitement of the voluntary muscles and locomotive organs takes place either from voli- tion, or from causes acting in opposition to it. Exercise promotes the synovial secretions, and the developement of the muscular structures and of their energies. But long-continued exertion increases the flux of blood to the related parts of the cerebro-spinal axis, and to the muscles them- selves. The morbid excitement, however, of vo- luntary muscles, which removes them out of the control of the will, has never been satisfactorily explained. Their more asthenic, or clonic anormal actions, which have been usually denominated convulsions,have been frequently traced to obvious lesion in the brain; but they have likewise been as truly referred to causes seated in the prima via, irritating the organic nerves, and, through them, the voluntary nerves. The almost universal state of sthenic spasm, called tetanus, has been as- cribed to inflammatory excitement of the arachnoid and other membranes of the spinal chord, from the circumstance of its having been detected in several cases, and by myself in two instances. But this change is as probably a consequence of the muscular excitation, as the cause of it How, then, does this state of muscular action originate ? The answer is not easy. But when we consider the connection — anatomically and physiologi- cally — subsisting between the muscular, the voluntary nervous, and the organic nervous, sys- tems, the reasons wherefore irritants acting on either of the latter will affect the former, or those affecting the muscles themselves, or even their tendons, will, in certain circumstances, through the medium of the nervous systems, ex- cite general muscular contractions of a perma- nent or recurring kind, will not appear so far beyond our comprehension. If we connect the causes of these affections with the earlier pheno- mena, we shall generally find, even when the ex- citing agent has acted on an external part, that the organic or sympathetic nerves have been thereby irritated; and that, owing to their influ- ence on the voluntary nerves, a state of spastic action is kept up in the voluntary muscles, or recurs in them at intervals, the brain itself being affected only in those cases which present lesions of its functions. This opinion, published by me in 1821, subsequent experience — pathological and therapeutical — has confirmed me in the belief of, particularly in respect of those cases in which the brain is free from disease. (See arts.CoN vu lsion s, Tetanus.) It follows, therefore, as corollaries from the foregoing, that whatever irritates the vo- luntary nervous system, or makes an extraordinary demand upon its influence, or any of its functions, will excite it, in that part especially upon which the particular influence or function called into operation depends, or with which the part princi- pally acted on is in communication; and will de- termine to it an increased flow of blood, which may, in certain circumstances, go on to inflam- mation or structural change; and that irritation propagated to the voluntary nerves will so ex- | press itself upon the muscles they supply, as to give rise to various states of spastic action, ac- cording as it originates in the sympathetic nerves, or in the brain, or is connected with other changes, functional or structural. Thus, mental exertion excites and determines the circulation to the head; muscular exertion, to the spinal chord; and local irritation occasionally gives rise, through the medium of the organic and voluntary nervous systems, to spasmodic action of the muscles of volition, of either a remittent, intermittent, or continued form. 82. (b) Secondary or indirect excitement, or re- action, is that state of increased function or func- tions following the impression of causes of a de- pressing or sedative kind: as when the powers of life, having been for an indefinite time more or less lowered by cold, by terrestrial emanations, or by the effluvium from the sick, react upon the state of depression, and give rise to various phe- nomena characterised by excitement, which thus becomes one of the terminations of direct Debility (see that article). Great diversity of opinion has existed as to the way in which the economy reacts upon injurious and depressing agents. The vis medicatrix natura, vital resist- ance, the conservative powers of life, with other terms, have been substituted as explanations .of what admits not of explanation, either by names, however expressive they may be, or by any other means. We can merely express what appears to be a law of nature, and describe certain re- sulting phenomena. We believe that the organ- isation is built up and kept together by the aid and intimate alliance of life, and that this princi- ple or endowment may be modified by changes in the structures, the instruments of its functions, — that, in short, so intimate is the union of life with all the organs and tissues, that it is con- stantly influencing them, according to its varying states, and being itself influenced by them, as they become changed, both in respect of its local alliances and its general condition. And all | that we can know respecting vital resistance and reaction must resolve itself into the general in- ferences, viz. 1st, That the innate powers of the vital principle, and the intimacy of its union with its material instruments, are such, that it opposes, by means of these alliances,— by its manifest- ations throughout the organisation, and by their mutual dependence and reciprocative influence ! — and by the manner in which it is influenced or modified by changes in its allied organs,—im- pressions of an injurious nature, the intensity of which is not so great as immediately to dissolve its connection with the structures, or at once to overwhelm its energies; and that, whilst it there- by resists the further progress of change, it at the same time restores that which has been induced; these phenomena constituting what has been called vital resistance : 2d, That when the morbid impression is energetic, a succession of changes generally follow in some part of the economy, owing to the circumstances now adduced, calcu- lated to remove the primary impression, and its more immediate effects, to recover the last ba- lance of vital action, and to restore the impeded or interrupted functions,— to these changes the terms reaction and secondary excitement have been applied; which, however, may be variously mo- dified, in form as well as in degree and duration: DISEASE — General Doctri&k of — Pathogeny. 577 3d, That when the impression and its immediate effects are very intense, relatively to the state of the person's constitution, the vital endowment may be thereby rendered incapable of resistance, or of developing any reaction; and, when this is the case, it sinks more or less rapidly, before the cause that effected it; sometimes, however, mak- ing certain feeble and abortive efforts at resto- ration, until, between its depressed state and the consequent changes on the tissues, its further manifestations and material alliance altogether cease. 83. If we endeavour to trace the succession of morbid phenomena characterising the simpler states of reaction, viz. those which take place from cold or from marsh miasmata, some idea of the way in which they are brought about may be formed. The impression made by cold upon the nervous, and, through it, upon the vascular systems, is evidently depressing, and vital action is diminished in the parts to which it is applied. Vascular determination, consequently, takes place to other, more especially to internal, parts; which are thereby excited, and their vessels enabled to react upon the greater quantity of blood sent to them. The consequence of this, in secreting organs and surfaces whose vital energy is not im- paired, is an increase of their proper functions, as an augmented flow of urine, or free discharges from the bowels; but, during a state of predis- position to vascular lesion in any of the parts experiencing the increased determination, inflam- matory action will be the result; and disorder will be extended thence to the whole frame, through the medium of the organic nervous and vascnlar systems, with especial affection of the internal organ primarily disordered. In other cases, a less simple process may take place; and the im- pression of cold not only may impede the exhal- ing and secreting functions of the surface or organ on which it directly acted, but, through the me- dium of the organic nervous system, may also interrupt the action of other secreting organs; and thus give rise to increased plethora, attended by the retention of elements in the circulation, which the healthy performance of the functions would have eliminated from it. The necessary consequences of these states will be reaction upon the distending and exciting contents of the vascular system; during the continuance of which, those organs which are most predisposed to dis- ease, particularly to inflammation, will suffer especially. When miasmata act upon the sys- tem, it may be inferred, from the more immedi- ate effects, that the nervous system of organic life is thereby especially impressed, and its influence diminished; the vital actions more immediately depending upon it impaired, and the secreting and excreting functions impeded. As those chan- ges are often gradually induced, a considera- ble period of latent or of slight ailment may exist; until at last they reach their acme, and the organic nervous energy is unequal to the active continuance of the circulation. When this point is reached, animal heat is imperfectly evolved; and the usual changes on the blood, as well as the proper functions of the viscera, are insufficiently performed. The necessary results are congestions of the large veins and yielding structures, and all the phenomena of the cold stage of intermittent or remittent fever; which rarely 49 proceeds so far as to overwhelm the power of vital resistances but more commonly ends in the developement of reaction. This is brought about by the greater fulness of the vascular system, and the more exciting properties of the blood, arising out of impeded secretion and excretion, and re- tention of exciting elements in the circulation, assisted by the influence of the rigors attending the cold stage in accelerating the circulation through the veins. 84. From what has been already advanced, it will appear evident that the nature of the primary action, or impression made upon the system by the depressing cause, will not only determine the character of the more immediate phenomena, but will also modify the state of reaction into which these may pass; and even the kind or type of action will not terminate with the develope- ment of this form of excitement, but will gener- ally continue long afterwards. This is remarka- bly exemplified by the morbid impression made by malaria, which will apparently act in the manner now stated, until the hot stage of the disease, or that of reaction, is produced by it; and, although this subsides, and is followed by free secretion, still the morbid impression is not thereby re- moved, or its type changed, but continues, in the organic nervous system, to exert its influence upon al. the vital actions, and to reproduce the same series of morbid changes, until either it is ex- hausted by their recurrence, or some internal organ undergoes structural change, and the dis- ease thereby becomes complicated, or in some respects modified. Such is the case especially when it is left to nature. That the morbid im- pression is made chiefly on the nervous system, is shown by the periodicity of action, by the cir- cumstance of the successive changes and free evacuations terminating the paroxysm not bring- ing the disease to a close, aud by the most effi- cacious means of cure being those which most energetically excite that system. That the im- pression is made upon the organic nervous, and not upou the cerebro-spinal, system, is shown by the more especial affection of those functions and organs which the former actuates, and the general absence of any considerable lesion, even of the functions of the latter. 85. C. The intensity and duration of excite- ment,whether primary or secondary,vary remark- ably, according to the cause, the constitution and habit of the patient, the circumstances in which he is placed, the agents or influences which continue still to act, and the states of the individual viscera, and of the circulating and secreted fluids. As re- pects intensity of excitement, it may be inferred that, where susceptibility and excitability are both great, intensity of excitement will also be great, but only relatively to the state of vital power; and that it will so much the sooner, and the more completely, exhaust itself. But, where neither is considerable, action will be moderate, and reac- tion will more slowly and less perfectly supervene. Where, however, the excitability is great, and the susceptibility not remarkably so, as in many ro- bust states of health, excitement may not be so quickly or so readily induced, but it will be more energetic and of longer duration. Thus we per- ceive that, in delicate, irritable, or nervous con- stitutions, excitement is easily produced, and soon arrives at its termination; whilst the reverse ob- 578 DISEASE — General Doctrine of—Pathogeny. tains in the robust. In the phlegmatic, lymphatic, and cachectic constitution, it is excited less per- fectly and with greater difficulty, and often as- sumes a modified form, particularly as respects its terminations. When excitement arises directly from a cause that is constantly present, as when an irritating body is lodged in the intestines, or in any of the tissues, it generally is continued, sometimes remittent, and of long duration ; but when it occurs indirectly, or from a depressing cause, it may be either imperfect or of short duration, the consequent exhaustion being great. This is evinced by diseases arising from malaria; reaction being less perfect, and vital depression with its effects more remarkable, when the cause continues to operate, owing to the residence of the patient in the locality which generates it. Excitement is, moreover, modified by states of the air — humidity lowering it, and a dry, pure air developing it — by mental emotions, by the condition of the circulating fluid as respects purity, and by previous health and habits. How these will influence the occurrence and course either of primary excitement or of reaction, is evident. The state of the vascular system as to fulness has also a great influence upon both : plethora favours local excitement and determi- nation; whilst, when very great, it prevents the free developement of reaction, and disposes to dangerous internal congestions in circumstances that would have otherwise induced a free and salutary reaction. The condition of the secre- tions, also, has a marked influence in the produc- tion and duration of increased vital action. The accumulation of morbid secretions in the prima via or in the biliary apparatus may either im- pede the occurrence, or shorten the duration, of excitement; or may determine it more especially to these parts. The state of the circulating fluid itself, particularly in respect of purity, will mainly influence this manifestation of vital power. If it contain stimulating elements in excess, reac- tion will be rapidly and strongly developed. But if materials of an opposite kind be carried into or developed in it, neither primary nor secondary excitement may at all appear; the conditions of life throughout the structures being thereby depressed and modified, and the living solids ulti- mately rendered unfit for the performance of their functions. 86. D. The consequences and terminations of excitement, primary or secondary.—(a) The con- sequences of excitement are, 1st, Various morbid productions or plastic formations, capable of or- ganisation in certain situations, particularly when the vascular system has been affected in a sub- acute form ; as the formation of coagulable lymph, and albuminous exudations in the form of false membranes, &c. 2d, The exudation of san- guineous, or sero-sanguineous, or muco-albumin- ous fluids; as in cases of acute irritation of mucous surfaces. 3d, The production of various changes in the structures (see Inflammation,) and ad- ventitious formations. — (b) The terminations of excitement are varied according to the system or tissue principally affected, the nature of the cause, and the concurrent circumstances. It has been stated as a general axiom, that excitement ter- minates in exhaustion, the degree of which is pro- portionate to the height to which the former had been carried. But there are numerous excep- tions to this, especially as respects reaction; which may be very slight, and yet the exhaustion may be extreme. The nature of the chief cause, numerous influences connected with the consti- tution of the patient, the surrounding media, and the mental affections, will modify the results.— a. Excitement, in any of its forms, may gradu- ally subside into a slight and chronic grade, in which it may give rise to certain changes in the nutrition or secretions of the tissues affected; to morbid depositions, and effusions in shut cavities or the parenchyma of organs; or to increased secretions from mucous and glandular parts.— p. It may also pass more rapidly into exhaustion, expressed more especially either in one of the nervous systems, or in the capillary and vascular system, or in the absorbent system, according as one or other of these had been principally dis- eased. (As to the effects of exhaustion on the different functions, organs, and structures, see the article on Debility, § 10—25.) 87. 2d. Of perverted States of Vital Power.—Having considered the simpler chan- ges of the conditions of life, as manifested in the functions and characterising disease, those which are more complicated are next to be discussed; and it remains to be shown, that the conditions and material alliances of life may not only be changed in degree, but also in kind—the change in kind being, in some cases, unconnected with either excess or defect of action; and, in others, associated with the one or the other; but more frequently with depression, or an irregular distri- bution of the vital energies, and concentration of them towards particular parts. The conditions of life present three states or stages of change in kind, without any reference to degrees of action: —1st, Modifications in function, or vital manifes- tation, the proper offices of the part being viti- ated, but the structure not being sensibly changed. 2d, Modifications of function, in connection with change in the constitution of the part; the natural tissues having been metamorphosed by an alter- ation of their nutrition or secretions, and by adventitious formations. 3d, Modifications in function and organisation in several parts, or in the whole of the frame; generally attended by a vitiation of the circulating fluids. 88. A. The conditions of life may be modified in kind, without any visible alteration of struc- ture. This state is often the commencement of the others now particularised; but it also frequently proceeds no further, or one form of it may merely pass into another, or terminate in health. Its slighter grades are more especially seated in the moving powers; the organic and cerebro-spinal nervous influences, and the vital properties of con- tractile parts, being chiefly affected; presenting, accordingly, a great variety of morbid phenom- ena, not strictly referrible to either excitement or debility, but consisting chiefly of alterations of tho sensibility of these systems; of pain and anxiety in their numerous forms; of cerebral affcctions,and disordered mental manifestations; of lesions uf the contractile and locomotive organs; of modifi- cations of the sensible and insensible contractility of parts, of their susceptibility and excitability; and of many changes in the state of the secre- tions and excretions, independently of those that relate to quantity. In its more exquisite and widely diffused forms, this state proceeds from DISEASE—General Doctrine of — Pathogeny. 579 several of those causes which I have termed specific; as malaria, animal and infectious ef- fluvia, endemic and epidemic influences, the rabid virus, various poisons received into the stomach, lungs, or circulation, &c. These, as well as the causes which produce the foregoing morbid conditions, evidently modify the nature of the vital functions, without any change of struc- ture or of the circulating fluids to account for the effect; and, when organic lesions do occur, they are consecutive, and sometimes accidental, alterations, which, in their turn, occasion a further change in the life of the part, or of the system generally. 89. B. The manifestations, as well as the struc- tural alliances, of life may be vitiated in a part of the body, from causes which determine to it a greater share of vital power; or which act fre- quently or permanently upon its excitability, and occasion an irregular distribution of life through- out the economy; or which abstract from it any portion of its nervous or vital influence; or mo- dify the condition of this influence by their primary impression or continued action, particularly iii constitutions predisposed to some hereditary vice, or imperfectly organised, or debilitated. A similar result may also follow unwholesome or innutri- tious food; the too frequent or excessive discharge of recrementitious fluids, as the seminal and pro- static; the absorption of an imperfectly prepared chyle, or of morbid secretions; or products gene- rated in the body; repeated excitation of an organ, or continued irritation of a particular part, ending in change of structure, &c. When the vital actions of a part are depressed, or modified in any man- ner, or from whatever cause, and the change continues, owing to the vital endowment being insufficient to overcome it by local or general reaction, and thereby to restore the healthy condition — the powers of vital resistance and restoration being incapable of removing the morbid impression, — a succession of alterations may supervene : the depressed or otherwise mo- dified life of the part will impede or diminish its circulation, or occasion its congestion; thereby facilitating changes in its fluids, or giving rise to alterations of its secreting and nutritive processes; and, ultimately, to various organic lesions of a chronic or malignant kind. Also, when the organic nerves and vessels of a part experience a continued or often repeated excitation of too slight a grade to extend far, or to affect related and sympathising organs, but sufficient to modify either its secreting or its nutritive actions, or both, its elementary tissues at last become more and more altered, adventitious formations are deve- loped, and the continued change in the conditions of life in the part at last gives rise to a complete metamorphosis of structure. The life of the dis- eased part, having thus formed to itself new alliances and instruments of altered manifest- ations, is thereby, in its turn, further acted upon, until the vital endowment is modified throughout the body ; the local alteration of structure expe- riencing, from this circumstance, a remarkable increase : and hence the properties of life, and of its structural alliances, act and react upon each other, until they become very sensibly vitiated, first in the part primarily diseased, and ultimately in the whole frame. Such appear to be the origin and progress of various changes of structures of a local, specific, and adventitious kind—tu- bercular, scrofulous, scirrhous, fungous, carcino- matous, &c. 90. C. The functions of life and the organisation are often vitiated, independently of grades of ac- tion, either in several parts, or in the whole frame. —Alterations of this nature are frequently the most advanced states of the foregoing; commencing, as I have now stated, in modified vital manifest- ation of a part, or of the whole body; and irre- gular determinations of it, which superinduce alterations of secretion and nutrition, give rise to changes of the elementary tissues, and the form- ation of others which are adventitious, and ter- minate in the state now under consideration, with sensible alterations in the circulating and secreted fluids. But this general morbid condition may also occur more rapidly from causes producing a very powerful and quickly diffused impression on the organic nervous system, and affecting the circulating fluids; as several of the poisons, espe- cially the animal poisons, infectious maladies of a pestilential or malignant kind, epidemic diseases, exanthematous fevers, &c. In all these, the grades of vital depression, or of excitement,— although most important circumstances, and each of them forming grand pathological conditions, when diverging considerably towards either ex- treme,—are much less distinctive features of the nature of the malady—are not so pathognomic— as differences of kind, which form the only true specific conditions by which we are enabled to distinguish one species from another; as typhus fever from plague, yellow fever from small-pox, I scarlet fever from measles, &c. In these, as well | as in several other maladies, grades of action merely, or the depression or the excitement of [ particular functions, or the irregular distribution of vital power throughout the frame, are far less attributes of their nature, than are perversions of their properties. The conditions of life in these are altered more especially in kind than in degree: this alteration in kind constituting the true morbid I state. Hence one principal reason wherefore a lowering treatment is much less efficacious in changing the morbid action, than remedies which j elevate the vital manifestations, and enable them to oppose progressive deteriorations in their con- ditions, and in the constitution of their allied I structures. The delirium, and the morbid and I apparently high vascular action, in many of such diseases, are often no reason wherefore remedies which excite the vital energies, and change their morbid actions, should not be employed. Every practitioner who has ventured beyond mere rou- tine, or the track pointed out by the numerous authors who have written to obtain that expe- [ rience of which their writings should have been the results, must have observed the beneficial operation of ammonia, camphor, cinchona, qui- ! nine, &c. in many cases of the above maladies; and even in states of action where it became a question whether or not an opposite practice should be employed. ! 91. D. Of vitiation of the conditions of life, and of their allied fluids ani structures, conjoinedwith depression or excitement.—(a) The association of depression with vitiation of the conditions of life, ! and with change of the fluids and solids, obtains in | the last stages of the maladies already instanced, particularly in those called malignant; whether ! originating locally or constitutionally and ad- 580 DISEASE —Alterations of Exhalation and Secretion. vancing slowly to the condition now being con- sidered, as carcinomatous and their allied diseases; or taking place in a more rapid and violent form, as malignant or adynamic fevers, the effects of animal poisons, &c. It would seem that all de- teriorations of the conditions of life are either consequences of, or otherwise related to, depression of them. If we trace the progress of those mal- adies in which the change in kind is the most conspicuous, we shall find that vital depression is a characteristic of the impression of their exciting causes, even although these causes may also irri- tate the vascular system, or impart irritating pro- perties to the circulating fluids; for extreme depression of the manifestations of life — of its conservative and restorative properties especially —is frequently conjoined with an apparently high and, as respects rapidity of action, extreme vascular excitement. When great depression is the attendant upon vital and structural deterior- ations, the sensible properties of the circulating fluid and of the tissues — the crasis of the one, and the vital cohesion of the other—experience rapidly progressive changes, until the bond of union between life and structure is dissolved; alterations of a very conspicuous kind taking place in various parts of the body some time before death. (See article Debility, § 11. 26.) 92. (6) The excitement which is sometimes associated with an alteration of the conditions and material alliances of life is essentially morbid, and is different from that which attends an other- wise unchanged or non-deteriorated state of the vital powers. This morbid excitement is gene- rally expressed in particular systems and organs; the vital actions of the rest of the frame being proportionately lowered: but, whether it affect chiefly the nervous or the vascular systems, or take place primarily or consecutively, it soon ter- minates in profound exhaustion, and in a more or less complete vitiation of the conditions and alliances of life. This is illustrated by the ad- vanced states of adynamic and epidemic fevers, by plague, &c. in an extreme degree; and by the worst forms of erysipelas and eruptive fevers in a less conspicuous manner. The excitement thus associated with other vital and material al- terations may proceed directly from its efficient cause, which may excite or irritate, whilst it otherwise affects, the organic nervous and vas- cular systems; or it may take place indirectly, or consecutively on depression, and be more or less a state of reaction, developed by changes in the circulating fluids, arising either from the absorption of irritating materials, or the interrupted elimi- nation of hurtful elements. But in either case a progressive deterioration is observed; the morbid conditions of life affect the secreting and excreting functions, and consecutively vitiate the circulat- ing fluids, and even the living solids; and the irritating or vitiated state of the former excites the vascular system; and thus alterations of the one reciprocally increase those of the others, either until the alliance of life with the structures can no longer be preserved, or until, in con- sequence of the exhaustion of the vascular action, which had been excited by the changes in the circulating fluid, and of the effects of this fluid on the secreting and excreting organs, the balance of vital excitement is inclined in their favour, a new action takes place, their functions are resumed, morbid matters are thereby eliminated from the system, and health is ultimately restored; the change being either ushered in by critical pheno- mena, or promoted by remedies, the operations of which are merely an artificial or substituted crisis. (See art. Crisis.) 93. IV. Disease of the Fluids and Sol- ids, originating in altered Conditions of Life, and generally in those al- ready discussed.—Morbid exhalation, secre- tion, and nutrition may be viewed as stages of the same organic action; exhalation passing into secre- tion, and secretion into nutrition. Thus we per- ceive the natural exhalations, during disease, assume the characters of a secreted or elaborated fluid, and certain morbid secretions become more or less organised. I shall therefore notice — 1st, The simpler changes of exhalation and secretion; 2d, Simple modifications of nutrition; 3d, Pre- ternatural exhalation and secretion, comprising the transformations and misplacements of these fluids; 4th, Preternatural or metamorphosed nutri- tion; 5th, Adventitious formations, or productions, foreign to the economy — consisting of secretions —(a) insusceptible, and (b) susceptible, of or- ganisation; and, 6th, Of destruction of parts. 94. i The simpler Alterations of Ex- halation and Secretion.—I have considered in distinct articles, on account of their great im- portance, morbid states of the Blood, and Con- gestions of this fluid. I shall here briefly notice changes in the exhalations and secretions.—A. The exhalations into shut cavities, or in the areolae of the cellular tissue, may be increased from the fol- lowing changes:— 1st, From deficient tone, re- ferrible either to the exhaling vessels and pores, or to imperfect vital cohesion of the tissues, or to both: 2d, From deficient action of the absorbents, depending on diminished vital power, or on ob- structions in their course: 3d, From increased determination of blood in the vessels distributed to these parts: 4th, From inflammatory action terminating in, or being followed by, effusion: 5th, From obstructed and retarded circulation of the venous blood returning from these places, par- ticularly in the liver, in the heart, lungs, &c; the consequent nervous and capillary distension fa- vouring augmented exhalation: 6th, From in- creased vascular or rather serous plethora, owing to the obstruction of some emunctory, — as ana- sarca, from the sudden arrest of the cutaneous and pulmonary exhalations; and this, as well as other forms of dropsy, from inflammatory or structural disease of the kidneys: 7th, From the sudden arrest of an accustomed discharge from the pul- monary or digestive mucous surfaces, the morbid exhalation being determined to the contiguous serous surfaces; and, 8th, From two or more of the foregoing states conjoined.^ (See art. Dropsy.) 95. B. Alterations of the secretions depend — 1st, upon the state of the organic nervous in- fluence; 2dly, upon vascular action; and, 3dly, upon the condition of the blood it«elf— upon the chief factors of organic action and life; and they are thus indications of the manifestations of this principle. They may be — a. more or less diminished, — as from causes which lower the organic nervous influence, or retard the cir- culation; p. or more or less increased, chiefly from agents which alter the distribution or determin- ation of organic influence, and consequently of DISEASE—Alterations of Exhalation and Secretion. 581 the circulation and vascular action, either by ex- citing the secreting structures themselves, and their intimately allied parts, or by depressing, impeding, or obstructing the functions of distant, and especially of other secreting organs, and from a superabundance in the blood of the elements of which the increased secretion is formed; v. or more or less altered from the healthy state, inde- pendently of diminution or increase of quantity, —as when the conditions of life are modified otherwise than in grade, and when the circulating flnid is vitiated, either generally, or merely in respect of the greater abundance of some one element; 9. or both diminished in quantity and altered in quality, owing chiefly to lowered as well as modified vital power, to changes in the blood, and to morbid vascular action or inflam- mation of the secreting organ; f. or, lastly, they may be both increased and vitiated, either from a morbid distribution, and alteration of vital in- fluence and action, owing to the impression of causes on remote but related organs, or from irri- tation or excitement of the nervous influence of the secreting structure itself, by agents acting either exteriorly to the vessels, or interiorly, through the medium of the blood. Thus, various substances received into the digestive canal will increase and alter the secretions of its mucous surface; and the accumulation of the elements of bile in the blood, with other effete matters, will excite the liver, and give rise to an abundant as well as acrid or otherwise morbid bile. Such seem to be the chief pathological states on which morbid secretions depend. 96. From what has been stated, it will be evi- dent that, although alterations of the secretions are often dependent upon vascular action in its various states, from augmented determination to inflammation and its results, and upon conditions of the liood, organic nervous influence has also a marked effect in generating them, and even in originating the vascular disturbances to which they have been most generally assigned by authors. And although the secretions are constantly and conspicuously disordered in fevers and inflam- mations, yet they are also often remarkably altered in other diseases; and, in some, even constitute the most prominent change from the healthy state. In fevers and inflammations, the secretions are more acutely affected, but are more disposed to a spontaneous and salutary change, than in chronic disorders. In those ma- ladies in which their alterations form the chief pathological state, their natural conditions are very slowly restored; and, even when the restor- ation is effected, their derangement is apt to recur from the slightest causes. This is exem- plified in diarrhcea, diabetes, and several other chronic diseases. 97. (a) The recrementitious, as the salivary, pancreatic, and gastric secretions; or the partly recrementitious and excrementitious, as the biliary and intestinal secretions; are more or less altered in most diseases, and from a diversity of causes. Agents, whose operations may be sufficient to excite the organic nerves, but not to produce in- flammatory action; or whose properties are cal- culated to affect the influence of these nerves, rather than the action of the capillary vessels; may give rise to an increase or other change of the secretions in preference to inflammation. 49* Thus, aromatics and stimulants will excite the flow of the gastric juices, but will not occasion inflammation unless taken in very large quan- tities; various substances will increase the in- testinal secretions, but not inflame the villous sur- face; and mercury, in small or moderate doses, will remarkably augment the salivary fluid, but, in excessive doses, will inflame the glands and diminish the secretion. The effects of sti- mulants upon parts related or contiguous to those to which they are applied, also show the influence of the nerves on the secretions,—as the action of certain odours and savours on the salivary and gastric secretions, and of various purgatives on the biliary fluid. Even mental emotions affect the secretions through the medium of the related or- ganic nerves supplying secreting structures; and this effect is not limited to the recrementitious fluids, but is also extended to those which are en- tirely excrementitious, as the urine, the sweat, &c. The influence of mental anxiety in pro- ducing both diuresis and enuresis, and of hysteria in occasioning the former, is well known. Defi- ciency of the recrementitious fluids causes dys- peptic, hypochondriacal, and other diseases of the digestive organs; impedes or otherwise modifies sanguifaction and nutrition; and favours the pro- duction of nervous affections. Morbid states of the biliary secretion are amongst the most im- portant in pathology. Impure air, want of ex- ercise, increased temperature, rich or full living, stimulating liquors, &c. change both the quantity and the quality of this fluid; rendering it either more copious, or of a deeper colour, and of a more acrid quality, than in the healthy state. Its more languid circulation through the ducts, or its undue retention in the gall-bladder, owing either to indolent habits, or to exhausted powers of digestion and assimilation, favours the absorp- tion of its more aqueous parts, increases its con- sistence, disposes certain of its constituents to crystallize or to concrete into calculi, and gives rise to various chronic disorders of the liver and of its related viscera. Obstructions to its passage or discharge, and various other circumstances, favouring its absorption on the one hand; and torpor of the liver, or suspended action of this viscus preventing its secretion on the other, and causing the accumulation of its constituents in the circulation; are important pathological conditions, and constitute no mean part of several acute and chronic maladies, besides those in which the biliary fluid is more especially disordered. (See Con- cretions—Biliary; Jaundice, and Liver.) 98. (6) The secretions which are elaborated by the intestinal mucous surface are often remarkably changed, both in quantity and kind. Diarrhcea, dysentery, and cholera present extreme increase and alteration, not merely of these, but frequently also of those poured into the digestive canal from the collatitious viscera, originating in the pathological states adduced above (§ 95.); and illustrate the action of morbid secretions upon the surfaces with which they may come in con- tact. When these secretions are produced in large quantity and altered quality, whether from a modified and excited condition of the vital actions, or from both, or from these conjoined with an impure state of the blood, the effects fol- lowing their passage over the villous surface are often very severe, and even disorganising. Thus, 50 582 DISEASE — Alterations of Exhalation and Secretion. an altered state of the salivary fluid inflames and ulcerates the mouth, tongue, and gums; and the irruption of a large quantity of acrid bile irritates the duodenum, excites severe vomitings and purgings, sometimes with spasms of the vol- untary muscles owing to the irritation of the visceral nerves acting upon the related spinal nerves, and, in more chronic cases when morbid secretion is prolonged, even excoriates the intes- tinal surface. A similar effect very probably is occasioned by the intestinal fluids themselves, as shown in dysentery. But the injurious opera- tion of the fluids poured into the digestive canal does not arise only from their morbid increase. Diminished secretion, if it be attended by the accumulation and retention of the fluid in the secreting viscera, and of the mucus on the villous surface, may prove equally detrimental, but more insidiously and slowly. Morbid in- crease of these fluids is usually an acute, and diminution of them a chronic, disorder. The latter is generally accompanied with alterations in their properties, especially if they are long retained. When the retention and alteration take place in respect of the mucus contained in either the solitary or aggregated follicles, dangerous or even fatal ulcerations, or other organic changes, may be the results. Their ac- cumulations on the intestinal surface favour the production of worms, indigestion, constipation, colic, &c. The manner in which one secretion may be greatly increased, whilst the rest are sup- pressed, is remarkably illustrated in pestilential j cholera. In this malady it would seem as if the ' efficient cause suppressed the vital manifestations of all other organs, determined the remaining vital influence and circulation to the digestive canal, and occasioned an uncommon increase and alteration of its exhalations; the serous portion of the blood being in great part evacuated in this situation, leaving a portion of its albumen lining the intestinal surface in the form of a muco-albu- minous and tenacious exudation. 99. (c) The excrementitious secretions are also , altered by the pathological states already speci- fied (§ 95.). The changes of these, as well as of the foregoing fluids, are important agents in continuing or aggravating disease, and furnish some of the chief indications of its nature, pro- gress, and terminations.—As the office of the , organs which secrete this class of fluids is to ! expel those elements which are effete, and would be injurious to the frame if retained in the blood, it must necessarily follow, that any interruption to this function, and especially a complete ob- struction or suppression of it, must be highly j injurious. The dropsical effusions in various cavities following interruption to the action of the kidneys, and the more acute effects of entire sup- pression of their functions, fully illustrate this. As a large quantity of ingested matters is carried into the blood, either directly from the stomach, or along with the chyle, and discharged from it by the emunctories, it is evident, not only that the kind of ingesta will affect very remarkably the properties of the excretions, but that obstruction or even interruption of any one of them will be followed by serious effects, unless some other organ perform an additional office, vicarious of that which is suppressed; and even in this case, ! disease will generally ultimately arise. 100. a. The menstrual evacuation, and even the lochia, may be considered as excrementitious se- cretions, interruption or morbid increase of them being followed by similar consequences to those arising out of suppressed perspiration. That the menstrual discharge has essentially a depura- tory effect upon the blood, is shown by the alter- ations which it undergoes from morbid states of the circulation; thus, I have seen copious cata- menia, the fluid being remarkably offensive, irri- tating, and otherwise sensibly altered from the natural state, form the crisis of erysipelas, and fevers; and a copious, offensive, and excoriating lochia evidently the means of preventing the accession of those adynamic and malignant dis- eases which often affect puerperal females, owing to the respiration of the impure air generated by several females confined in one lying-in apart- ment. The catamenia, moreover, is diminished, increased, vitiated, or changed into a serous or mucous secretion — into fluor albus — by the same agents and pathological conditions (§ 95.) as affect the other excretions. 101. p. Morbid states of the perspiration, in- dependently of its increase or decrease, are not infrequent attendants on both acute and chronic maladies. They may even accompany appa- rently sound health, particularly when the bow- els are habitually constipated; this evacuation being sometimes so offensive, or both copious and offensive, as to render the person thus affected a nuisance to those near him. In this case, the skin evidently performs an office vica- rious of the diminution of the intestinal secre- tions. The perspiration is generally promoted by excited vital action of the cutaneous surface ; in which case it is fluid and warm. But it may also be much augmented by a very opposite con- dition of vital power, as by syncope, the skin being cold and clammy; or by the extreme vas- cular depression occasioned by excessive fear. In these cases, the lost tone of the integuments, and of the excreting pores, allows the escape of a portion of the fluids contained in the superficial vessels. This change also occurs in many in- stances of extreme vital depression, and shortly before death in many diseases. It is a pathogno- monic symptom of pestilential cholera, in which it is most remarkable; the cold, wet, livid, and shrunk surface, being the result not only of the suppressed vital powers, but also of the circula- tion of venous blood. 102. •/. The urinary, of all the excretions, ia the least frequently suppressed; the consequences of such a state being, if not soon removed, the most dangerous, or rapidly fatal. Whilst this excretion is very much influenced by the quantity and nature of the ingesta, and by the temperature and humidity of the air, it is also variously altered by disorders of digestion, sanguifaction, and cir- culation ; but more particularly by the conditions of the blood itself, by changes in the nervous in- fluence, and by injuries to the spinal cord. On the other hand, interruptions of the urinary dis- charge affect the quantity and quality of the cir- culating fluid, disorder the nervous systems, ulti- mately increase the exhalations aud the other secretions, and change the constitution of the soft solids. The other pathological relations of diseased urine are fully explained in the articles Diabetes and Urine. DISEASE — Preternatural Exhalation and Secretion. 583 108. ii. Simple Modifications of Nutri- tion may affect the whole frame, or a particular tissue or part, or merely a circumscribed portion of a single structure. The entire absence of parts, or deviations in the distribution and arrangement of the elementary molecules and tissues, producing the various kinds of monstrosities, will be left out of consideration, they being of less practical inter- est. Those changes which are most important may be resolved into the following : — 1st, Alterations of bulk; 2d, Modifications of density and cohesion, either of which may lead to various complicated lesions. Hypertrophy, or augmented nutrition, perhaps never affects all the tissues simultaneously; and although generally a disease, sometimes of dangerous import, yet, when seated in the mus- cles of voluntary motion, it cannot be considered in any respect as a morbid change. It may be conjoined with softening or with induration, with increase or diminution of density and vital cohe- sion. Atrophy, or impeded nutrition, may also be associated with similar lesions. Any one of these four alterations, or either hypertrophy or atrophy conjoined with softening or with indura- tion, may commence in one, or at most two, of the elementary tissues, and extend to those most intimately connected with it. In these modifica- tions of nutrition — producing variations in size and density — it is understood that the tissues still retain their distinctive characters. (See Atrophy, Hypertrophy, Induration, Softening, and Ulceration.) 104. iii. Of preternatural Exhalation and Secretion. — A. Transformation of the Natural Exhalations and Secretions.— (a) The exhalations of serous surfaces, or shut cavities, may be altered according to the state of organic action in the surface producing them.— /. Exhaust- ed vital action and cohesion will be followed, ac- cording to its grade, by the effusion of an aqueous, serous, or sero-sanguineous fluid, the relaxed state of the capillary pores and serous tissue allowing, instead of a simple halitus, the escape of the watery parts of the blood, sometimes with a por- tion of its albuminous constituents, and even of its red particles; and, under certain circumstances, as of obstructed return of blood from, and congestion of, adjoining parts, and dyscrasia of this fluid,— states not infrequently consequent upon exhausted vital power, — the effusion of a portion of blood itself. — p. When depression of vital power and diminished cohesion of the serous surface is asso- ciated with increased action of the vascular system and contamination of the circulating fluid, as in several adynamic fevers, the exhalations are not merely increased, they are also turbid and of vari- ous shades of colour, from a dirty grey to a dark brown. — ;•. When organic action is morbidly in- creased in serous surfaces, the exhalation is chang- ed into a sero-albuminous matter, which is at first fluid or semi-fluid, but which afterwards assumes modified states, according to the grade of consti- tutional power and morbid action, and the partic- ular characters such action presents, — whether that of pure phlogosis or sthenic inflammation, or that of diffusive phlogosis or asthenic inflamma- tion, or of the intermediate forms. If the organic action consist chiefly of the former, in an acute or sub-acute state, the effused matter will be more or less albuminous, concrete, and spread over the inflamed surface in variable quantity, and will contain a turbid serum in the opener spaces. If the inflammation be of a diffused kind, the effusion will be more copious, and fluid, varying from a turbid serum to a dirty, deep- coloured, or flocculent, or sero-purulent, or albu- mino-puriform matter, without any adhesion of the opposite inflamed surface; and thus the mor- bid exhalation will be altered in all acute cases, as the inflammation, owing to the degree of vital power, has partaken more or less of the sthenic or asthenic state. If the inflammation be of a chronic kind, the effusion will be more dense and coherent, or even become organised; and, when the albuminous exudation consequent upon acute phlogosis has given rise to adhesions, or passed into a chronic state, they become transformed into cellular bands, with or without a turbid or flocculent serum contained in the unadherent spaces. 105. (6) The exhalations and secretions from mucous surfaces are also remarkably changed by the states of vital power, of structural cohesion, and of organic action. —«. When vital energy and cohesion are much diminished (§ 91. 95.), the watery exhalation from these surfaces may be increased, and transformed to a serous, or sero- sanguineous, or bloody discharge; particularly in some malignant and cachectic maladies. If the tone of the extreme vessels be lost, vital action being at the same time depressed, the sanguine- ous exhalation will be what has usually been termed passive, and the crasis of the blood — both that effused, and that circulating in the body — will be either lost or deficient. But if vascu- lar action be increased, the capillary vessels and pores being either expanded or relaxed, or the cohesion of the mucous tissue greatly impaired, the haemorrhage will assume more of the active characters, and the coagulation of the effused blood be more or less perfect. Between these grades of action, however, — the terms active and passive expressing the opposite extremes, — there will be eveiy intermediate degree; much of the appearances of the exhaled blood being those of its condition — or depending upon its condition previously to its discharge. (Sec Hemorr- hage.) 106. p. Not only may the purely exhaled fluid he thus altered, but both it and the more strictly secreted fluid, as the mucous, may be disordered either consecutively or coetaneously. This chrvige is usually a consequence either of local determi- nation and irritation, or of inflammation of a slight or specific kind. In such cases these fluids are thin, serous, ropy, glairy, albuminous, muco- albuminous, or puriform, frequently in succession, and secreted in large quantity. Thus, when the respiratory mucous surface is irritated by catarrh, its natural secretion, which is scarcely evident in health, becomes successively transformed into these states; and a similar effect follows irritation of the digestive surface. In acute and sub-acute inflammations of this tissue, its exhalations and secretions are altered, either to a muco-puriform matter, streaked with blood, or to a puro-albumi- nous fluid, or to an albuminous exudation, which concretes in the form of a false membrane in the surface that produced it. These modifications of the morbid productions are referrible to the de- I gree in which either the exhaling or proper ves- i sels of the surface, or the mucous follicles, are 584 DISEASE—Preternatural Exhalation and Secretion. respectively affected, and to the grade of vascular action. 107. (c) The exhalation usually poured into the areola of the cellular tissue may be similarly transformed, and the various alterations may re- spectively depend upon the states of vital power, of vascular action, of structural cohesion, and of the crasis of the blood, particularised above,— a watery, serous, sero-sanguineous, a purely san- guineous, sero-albuminous, or a puriform fluid being poured out in this tissue, either where it connects more external or superficial parts, or forms the parenchyma of the viscera. In such cases, the transformed exhalation is either diffused or circumscribed, according to the state of action, and the consequent nature of the transformation. Thus, great depression or exhaustion of vital pow- er and cohesion is connected with the diffused infiltration of a serous, or sero-sanguineous, or even a bloody fluid, and, if this state be attended by increased vascular action, with the infiltration of a puriform, or sero-puriform, or even an ichor- ous matter. But when vascular action is in- creased, and partakes of the phlogistic or sthenic characters, a puriform matter is formed, and is circumscribed (seearts.ABscF.ss andCELLULAR Tissue). The diffused or circumscribed depo- sition of a puriform fluid, which sometimes occurs in the cellular tissue, and the cavities of joints, consecutively upon inflammation or suppuration in the veins or in remote parts, during states of vital depression, have been explained in the arti- cles now referred to, particularly the former (§ 29.). 108. B. Of the Exhalations and Secretions which are adventitious to the situation, — or mis- placed Secretions.—(a) Fatty matter has, in rare instances, been found in unnatural localities; as in the blood, in the urinary bladder, and in the intestinal canal, either in its cavity, or forming small tumours in the connecting cellular tissue of the parietes. — (6) A yellow matter has fre- quently been observed colouring the various tis- sues and the secreted and excreted fluids, oc- casioning jaundice; and, although generally re- ferred to the colouring matter of bile, has only recently been proved by chemical analysis to consist of that substance. This change is often connected with biliary obstruction or disorder, but in many cases no such connection exists, as far as can be ascertained during life or after death. In such instances we must infer — and the inference is borne out by the very sudden manner in which the change takes place, and by other circumstances—that other organs and tissues than the liver may acquire the power, under certain circumstances, of forming or sepa- rating the colouring, and probably other principles of the bile from the blood. I have been often convinced by practical observation, that more than one of the principles of the bile have passed off with the perspiration, in persons whose biliary organs were torpid, and in those affected by chronic cutaneous disorders connected with hepa- tic obstruction, even although the colour of the skin remained unchanged, (c) Cholesterine, an- other principle of the bile, has also been found in various secretions and structures; and therefore it must likewise be inferred, that it also may be sometimes separated from the blood by the tissues, (d) The urine, and certain of its pecu- liar principles, have been secreted in unnatural situations. Facts of this description were often related by the older writers; and the more pre- cise researches of modern times have determined the circumstance, as respects the presence of some of its principles in the supplementary se- cretions, which were formerly considered a me- tastasis of the urine : thus, uric acid has been detected in the sweat, and in gouty concretions, &c. 109. In respect of the causes of the misplace- ment of the secretions, it may be concluded that, ;is the elements of all the secretions exist in the blood, they may be occasionally separated from it by other organs or tissues, than by those which are the usual instruments of such separation and combination into the state of perfect secretions, particularly when the organs thus appropriated are diseased to the extent of impeding their functions. In such instances, however, the accumulation of the elements in the blood does not excite other organs to the elaboration of a secretion similar to the natural one; but merely to the elimination of the particular element or elements that may he in excess, in a separate form or different state of union to that which it naturally presents. Thus, when the urine is suppressed, it is only urea, or uric acid, that is found in the supplemental evacuations; or when the bile is obstructed, it is not elaborated bile, but certain of its principles, especially its colouring matter, that tinges the se- cretions, and, in aggravated cases, the structures; or when the milk is suppressed, it is not milk that is found in other situations than in the breasts, but caseum, &c. In the cases of obstruction of the urine and bile, the respective organs being unable, either from paralysed nervous influence, or inflammation, or structural change, to perform their depuratory functions, the aqueous and effete elements which consequently accumulate in the blood are either separated by the tissues, or pass off through other channels, but in dif- ferent states of combination, the appropriated instruments of the function being incapable of elaborating them into the natural secretions. In cases, however, where this unnatural separa tion of elements occurs without evident inter- ruption of the functions of the organ destined to excrete them, we must necessarily infer an exuberant formation of the elements in question in the blood, and a consequent elimination of them through additional channels. It is not uncommon to observe jaundice associated with a natural or copious secretion of bile, and even with a greatly augmented evacuation of this fluid; we must, therefore, conclude that the col- ouring elements are formed so abundantly in the circulation, as not to be sufficiently excreted from it even by the increased action of the liver; and, consequently, that they are accumulated to the extent of being separated by the different struc- tures. It may further be conceded, that the elements may be combined into more or less perfect secretions in the organs destined to ex- crete them; but that, before they are discharged from them, or excreted from the system, they may be occasionally taken into the blood, and separated from it by other structures, and through different ways. 110. iv. Metamorphosed or Transform- ed Nutrition—or that change which consists of DISEASE—Metamorphosed or transformed Nutrition. 585 the transition of one tissue into another—is of a less simple kind than that noticed above (§ 103.)—a. M. Andral has shown that the same principle of developement which obtains in the foetus, extends also to the morbid transformations of the natural tissues; and that as the cellular is the matrix of the other textures, 60 it may, from disease, be changed into most of the other simple structures. There are, however, certain facts connected with such alterations deserving notice:—1st. Cellular tissue, in being changed into some other, no further affects the proper texture of the organ, which it either invests or of which it forms the parenchyma, than in causing its atrophy in some cases. — 2d. Cellular tissue cannot be transformed into the nervous, unless in situations where the latter pre- viously existed : thus, nerves that are divided, and of which a portion is removed, are first connected by cellular tissue, and subsequently by the ex- tension of medullary substance from each divided extremity. — 3d. Other tissues, whose continuity has been dissolved, have the breach repaired, in the first instance, by means of the production of coagulable lymph, which passes into the state of cellular tissue; this latter being frequently after- wards transformed into a texture analogous to that which was divided; thus, divided muscles are re- united by a fibrous tissue; and so on, as respects bone, cartilage, &c.—4th. The nature of the trans- formation of cellular tissue is sometimes regulated by the functions of the part: thus, when subject- ed to friction, it becomes a serous membrane; when exposed to external agents, it becomes teg- umentary, &c. — 5th. Other tissues, besides the cellular, may be transformed, but the alterations are similar to the natural changes they experience in the processes of foetal growth : cartilage being converted into bone, the mucous tissue into the cutaneous; or a reverse course may be followed, in respect both of these textures and of the mus- cular tissue, which can be changed only to the fibrous. Hence the metamorphoses of cartilagin- ous, osseous, fibrous, muscular, cutaneous, and mucous structures are much more restricted than those of the cellular. — 6th. All tissues, when remarkably atrophied, present evidence of degen- eration towards their primitive or rudimentary state, viz. to cellular tissue. 111. ,*.The causes of the mutation of one tissue into another are not easily ascertained. Some have ascribed it to inflammation or irritation.— By ascribing it to modified nutrition, we merely express an obvious fact, the cause of which is thereby not more nearly approached. It certainly is not occasioned by inflammation, although sev- eral of the transformations may be accidental or contingent consequences of that condition, espe- cially in its slighter grades; for, however we may irritate, or determine blood to a part, we 6hall not transform it, unless under circumstances identical with those that are concerned in the production of those alterations. The series of an- alogous changes that take place in the foetus is not connected either with irritation, or with in- flammation, or with opposite states of organic action. We can, therefore, impute the meta- morphosis only to modifications in the conditions and manifestations of life influencing the nutri- tion of the organ or part; for we know that in- crease of function, or of vital manifestation, will often occasion a transformation of nutrition in a certain direction — will change cellular tissue to a higher grade of structure, as in the develope- ment of the organs of the foetus; whilst the dim- inution or privation of function — that is, of its due vital endowment — will transform the organ which performed it into a more rudimentary tissue: thus, a part becomes atrophied from being unex- ercised, an unemployed muscle is reduced to a pale fibrous structure, and an impervious artery or duct to cellular tissue. In briefly noticing the specific metamorphoses of tissue, I shall com- mence with the simplest, and generally the earliest change, in the ascending scale of trans- formation. 112. (a) The cellular tissue having always existed as the matrix of the compound structures and organs, it is obvious, when, owing to sus- pended or abolished function, the superadded organisation devoted to such function is lost, that the cellular tissue will then remain as the primitive structural base. This is shown by the evidence already adduced. The coagulable lymph exuded during inflammation of serous surfaces may be- come organised into cellular, and even into serous tissue, and be the matrix of certain other changes (§ 140.). 113. (b) The serous tissue, and the cellular, are often transformed one into the other. Cellular substance may have serous cysts developed in it, in almost any part of the body, either from fric- tion or pressure; or from the lodgement of a for- eign body, or the existence of a coagulum, &c. But, independently of these causes, it may have cysts of various dimensions formed in it, either where it invests the different organs, or enters into their internal structure; the parenchymatous organs sometimes being either partly or altogether transformed into a serous sac, or having these productions attached to them. When thus de- veloped, they have been attributed to irritation by some, to a diminution of the natural action by others, and to perverted action by several pathol- ogists. There can be no doubt of the last being the case, whether other states of action may ac- company it or not. 114. u. Serous cysts vary from the size of a millet seed to that of a child's head; they exist either singly or in clusters, have their external surface in contact with the organ in which they are produced, and are either intimately connected with the cellular tissue surrounding them, or en- tirely without any organised connection. Red vessels are seldom seen passing into them. The structures immediately surrounding them may re- tain their natural appearance; or may lose it for a time and regain it; or may be shrunk and con- densed ; or be altogether atrophied, and expanded over the cyst, as in the liver, brain, lungs; or be merely congested; or moreover be softened, in- durated, or surrounded by pus, or by tubercular matter, or by blood. In this last case, the cysts themselves are sometimes broken down, or par- tially destroyed. The investing cellular tissue may also become fibrous, cartilaginous, osseous, or even calcareous; and additional layers thus may be superimposed on the original cyst. The internal surface of the cysts may be smooth, or may present changes altogether similar to those which serous membranes experience from disease; it may be uneven, rugose, granulated, covered by specks of concrete albumen, or lined by false 586 DISEASE — Metamorphosed or transformed Nutrition. membranes, with or without cellular bands or partitions running across the cavity. 115. ,*. These cysts usually contain a limpid fluid, but other substances have been sometimes found in them; viz. 1st, a serous fluid tinged with the colouring matter of blood; 2d, blood, with its fibrinous coagulum; 3d, fluid or semi- fluid substances, of a dark colour, probably con- sisting of altered blood; 4th, a flocculent serum; 5th, a mucous fluid; 6th, a fatty substance; 7th, cholesterine; 8th, the different varieties of pus; 9th, tubercular matter resembling that found in the lymphatic glands of scrofulous persons; 10th, a solid elastic substance, probably consisting of altered albumen; 11th, several species of entooza. Occasionally two or more of these substances are found in different compartments of the same cyst; and without any appearances in its parietes to ac- count for the circumstance; thus furnishing an additional proof that the state of the secretion does not always arise from any appreciable modi- fication of structure. As to whether these cysts are formed before or after the matters found in them, it may be stated that, in respect of those containing the first three kinds of fluids, and pos- sibly of some others, there can be no doubt of the effused fluid having caused the formation of the cyst enveloping it; but as to those that contain different productions in separate parts of the cells, it must be inferred that the matter is secreted by the parietes or part of the cyst in which it is found. 116. (c) Mucous membrane may be produced from the transformation of the cellular tissue — 1st, in the place of the old mucous membrane, which had been ulcerated or otherwise destroyed; 2d, in abscesses without external outlet; and 3d, in abscesses having some external outlet, and old fistulous passages. In the progress of this change, the cellular tissue becomes successively smooth, vascular, and raised to the same plane as the continuous surface. It then admits of being de- tached in shreds from the subjacent tissues; and, in the alimentary canal, ultimately becomes stud- ded with villi. But in abscesses and fistulae, villi are not formed; and neither there, nor in the digestive canal, does the transformed mucous surface contain mucous follicles. Meckel and Andral record some cases, in which the internal surfaces of cysts containing a viscid fluid could scarcely be distinguished from mucous membrane. I have seen this appearance in the ovarium, where it has been principally met with. The free surface of the false membranes formed on serous surfaces has, in one or two instances, where there existed an external opening, been converted into a mucous-like tissue. 117. (d) The cutaneous texture is generally incompletely reproduced after being destroyed; the newly formed part being composed of a cel- lulo-fibrous layer, without the vascular tissue in which the colouring matter is deposited. Owing to this circumstance, the cicatrices in the black races are usually white. But there are excep- tions; the vascular layer being occasionally de- veloped at a later period, and the newly formed texture assimilated to the surrounding surface. When mucous membrane becomes constantly exposed to the air, it generally assumes more and more of the characters of the cutaneous structure, but the transformation is by no means complete. 118. (e) Fibrous productions are also evidently formed at the expense of the cellular tissue, the change from the latter admitting of being traced through its various gradations. They are gene- rally composed of delicate filaments, sometimes parallel to each other, at others matted together or interlaced, and occasionally coiled, convo- luted, or rolled up; and usually containing cellu- lar tissue between the fibres. These productions may exist as bands, distinct patches, and as rounded or irregular bodies. They may be either pale, or slightly vascular, or exceedingly so ; and be disposed in the shape of cords; or in that of membranes, surrounding or covering other parts or adventitious formations; or iu the form of tumours. 119. a. Fibrous tumours vary as follows :—1st, They are homogeneous throughout, and consist almost entirely of condensed fibres; 2d, They are lobulated, having cellular tissue interposed be- tween the lobules, in which the fibrous structure is more or less distinct and variously disposed, as stated above; and, 3d, They are, according to M. Andral, granulated, the granules being dispos- ed in lobules, connected by cellular substance. Fibrous transformations often undergo further changes, portions of them becoming cartilaginous, or even osseous. But, instead of these changes, they sometimes experience acute or chronic in- flammation, which may disorganise either the fibrous structure or its connecting tissue, giving rise to infiltrations of pus, or of blood, or deposi- tions of fibrine, the purely fibrous tumour thereby undergoing a complete metamorphosis. , 120. p. To what cause is the fibrous transfor- mation to be imputed ? This can be answered only by adducing the circumstances under which it has been observed to occur. — 1st. Fibrous growths sometimes appear in an apparently healthy state of the organ in which they are found, and are so completely isolated, a few delicate cellular and vascular connections except- ed, as to admit of being removed without affect- ing the adjoining structure. — 2d. The proper tissue of the organs has occasionally disappeared as the cellular tissue has become, transformed into the fibrous state. — 3d. The organs in which they are developed are sometimes the seat of inflam- matory action, but it cannot be determined wheth- er inflammation is the cause or the effect of the transformation. From these facts it may be in- ferred, that no conclusion, as to the immediate cause of the production of fibrous growths, can be offered with confidence; but that they may probably arise from altered organic nervous influ- ence of the part modifying the state of vascular action and nutrition. 121. (e) Cartilaginous transformations are often found under the same circumstances as the fibrous. They are met with in the following situations : — 1st. In the cellular tissue interposed between or- gans, or connecting different textures,—as in that subjacent to serous membranes — usually in the form of grains, large spots, or irregular depositions or incrustations; and either unattended by any other lesion, or accompanying changes in the se- rous membrane under which they are produced, or in the substance of the viscus; these changes being of the most diversified kinds in the different cases. They may also occur in the cellular tissue sur- rounding morbid secretions and productions, DISEASE — Metamorphosed or transformed Nutrition. 587 either as masses, or as membranes; and of them- , selves, or with the serous or the fibrous transform- ations, or with both, may form the cysts or en- velopes of these secretions.—2d. In the structure \ of parenchymatous organs, the cartilaginous pro- ductions are formed, like the fibrous tissue, at the expense of the cellular. They may be deposited in masses, or in the form of envelopes o'f various morbid secretions. Whilst cartilage is most fre- quently formed beneath serous membranes, these membranes themselves never experience this j change. It is rarely produced in the cellular tissue under the mucous or villous coats; and very rarely in these coats themselves, and then only consequently upon repeated or prolonged irritation. The osseous tissue may also be trans- formed into cartilage. But in respect of the change of muscle, and of parenchymatous viscera I —as the liver, spleen, kidneys, &c.— into car- tilage, it is more probable that the developement of this substance in the cellular tissue merely causes the disappearance of the proper structure in the part thus altered. There is, however, little doubt of a portion of brain being sometimes ] changed into cartilage. — 3d. hi cavities lined by serous or synovial membranes, cartilages have 1 been found, either entirely loose, or attached by a membranous prolongation or pedicle to some part of the parietes. They vary from the smal- lest size to that of a bean, and are of different forms. They are generally homogeneous and elastic, and sometimes they contain osseous points in their interior. They have been found in the peritoneal cavity, by Laennec and Andral; within the serous membrane of the brain; within the tunica vaginalis testis; in nearly all the articu- lations, but most frequently in the knee and shoulder joints; and even loose in the interior of serous cysts, by Andral. As to their formation, this pathologist thinks " that they derive their origin from the fluid exhaled in serous and syno- vial cavities;" whilst Bcclard and Laennec suppose that they are originally formed on the external surface of the membranes lining these cavities, and that they gradually protrude before them the portion of membrane covering them, thereby giving rise to the pedicles by which they are sometimes attached to the sides of the cavities. Morbid cartilaginous formations vary from a fibro- cartilaginous or mixed state, to one purely cartila- ginous, in which the internal structure is perfectly homogeneous; they also vary in firmness. They occur in the following situations in some one of these states:—1st, In false articulations; 2d, At the extremities of bones of which a portion had been long previously amputated; 3d, In the situa- tion of ligaments belonging to anchylosed joints; 4th, In cicatrices; 5th, in compound tumours of the uterus, ovaries, and thyroid; 6th, In the form of incrustations or patches, in the parietes of arteries; 7th, In the cysts and envelopes of morbid formations; 8th, In certain parenchyma- tous organs; 9th, In the interior of articulations; and 10th, In serous cavities, both natural and morbid. 122. (/) Ossiform formations differ in form, and somewhat in constitution, from the natural osseous tissue; and are generally confined to the cellular, the fibrous, and cartilaginous tissues. —ix. The cellular substance is not susceptible of this cliange in all parts of the body; for ossific deposits have not been found in the sub-mucous, although frequently in the sub-serous, cellular tissue; the serous membrane apparently still covering the osseous formations, and giving them a smooth pale surface. This change has been found in the sub-serous tissue in every part of the frame; and it generally begins with slight thick- ening, and the infiltration of a turbid fluid; morbid nutrition, very evidently in this instance, aud, in- deed, in most other cases, as I have above con- tended, commencing in vitiated secretion. The connecting cellular tissue between the coats of arteries, especially that below its serous coat, is still more frequently ossified than the foregoing. Also the cellular substance surrounding fistulous openings, foreign substances, and adventitious se- cretions or productions, often become incrusted by plates, or grains, or complete layers of osseous matter. Thus tubercles, hydatids, &c. are some- times contained in osseous envelopes. 123. p. Ossification of fibrous and cartilaginous textures is a part of the process of developement in foetal and early life; and the process goes on through life, although generally in an imperceptible man- ner, until old age advances, when it extends more rapidly, and seizes on additional parts of these tex- tures; the fibrous tissue of the arterial system, and the cartilages of the ribs, larynx, trachea, &c, being then often converted into bone. But when parts not liable to this change in old age are affec- ted by it, or when those disposed to it are prema- turely transformed, the circumstance is referrible to disease. The experiments of M.VI. Cruveil- hier and It a ye r show that a certain degree of inflammatory actiou or vascular injection of fibrous, fibro-cartilaginous, or cartilaginous tissues precedes the osseous deposit; and hence the reason that fractures or injuries are often followed by ossification of the adjacent parts of these tex- tures; and that simple irritation of a slight but continued form has given origin to this alteration. But, in many instances, no cause or appearance of inflammatory irritation could be traced to the ossified part; as when the coats of arteries, the dura mater, the capsule of the spleen, &c. are thus affected. 124. y. The form, texture, and constitution of ossiform formations vary much, both from one another and from the natural structure. As to form, they are—1st, Granular, and either isolated or in groups, their number being extremely va- rious, and sometimes remarkably great; their size extends from a minute point to that of a pea; they are rounded, with either a smooth or a rough surface.—2d, Lamelliform or membraniform — developed in the adherent surface of serous membranes, or in the parietes of cysts, &c.— of various sizes, and sometimes of several inches in diameter, and consisting of thin irregular plates. —3d, Amorphous,—generally found either alone, or in conjunction with other morbid productions in the parenchymatous organs; they consist more of a phosphato-calcareous deposition, than of an ossiform formation. Their texture is—1st, Ho- mogeneous, and without fibres or any division into compact and spongy parts; 2d, Obscurely fibrous or radiated, and more nearly resem- bling the natural flat bones. The constitution of natural bones is generally uniform; but that of the ossiform productions varies remarkably in respect both of their earthy or saline consli- 588 DISEASE — Adventitious Secretions and Productions. tuents, and of the animal matters they con- tain. In some instances, the calcareous salts are found with little or no admixture of animal mat- ter. 125. v. Secretions and Productions ad- ventitious to the Economy.—The morbid productions about to be considered present an infinite variety of appearances, in respect of con- sistence, colour, form, &c, occur under the most opposite circumstances, and are connected with the most diversified phenomena at their origin and during their progress. They have all a ten- dency either to increase by the juxtaposition of new particles; or to grow by the assimilation or intus-susception of matters transmitted to, and circulating iu, their own vessels. But, in either case, they undergo various alterations, arising out of their own intrinsic properties, or of the sur- rounding parts, or of the state of the constitutional powers and vascular action. Such of them as are unorganised are liable to changes chiefly from the conditions of the system, and of the parts in which they are seated. These changes are of a more limited extent than are experienced by those j which are capable of performing certain inde- pendent actions; and are generally confined to the removal by absorption of the more fluid parts when they are soft, and of the effusion of a fluid l matter when they are hard and irritating to the j parts containing them. Productions, however, which become organised, exercise functions of their own: they have become the instruments, under the influence of a derived vitality, of per- forming and secreting nutritive functions peculiar to tnem; and they thereby not only perpetuate and extend the morbid condition in which they originated, but also superadd others, either of a local or constitutional kind, or both. 126. a. The local changes connected with ad- ventitious productions are various: — 1st. The parts in which they are developed may be natural, or merely compressed by their bulk. — 2d. The surrounding parts may be inflamed, injected, or congested, and variously coloured. — 3d. They may be either indurated or softened, at the same time that they are pale or injected. — 4th. They may be hypertrophied, or remarkably atrophied in other instances; but most frequently the latter; the presence, and probably the pressure, of the adventitious formation diminishing their nutritive action. —5th. They may exhale or secrete a fluid or puriform matter, which may dissolve the in- organised productions, or soften them, and dispose them to undergo further changes. The states now enumerated of the surrounding parts, or cer- tain of them only, may take place in succession; and may follow one another with various degrees of rapidity. 127. p. The phenomena which attend their commencement are very diversified; but the powers of life more frequently evince various grades of depression, and even of perversion, than those of excitement. In many instances, however, such changes are very slight or scarcely percep- tible ; but they generally become very manifest in the progress of the morbid production; the func- tions of organic life —circulation, secretion, nutri- tion, excretion, &c. — experiencing more or less disorder. When affecting internal viscera, this disturbance may exist long without the nature of the lesion being more than suspected. But the symptoms, local as well as constitutional, will vary not only with the seat, but with the changes constantly supervening in the productions them- selves, and iu the structures surrounding them. 128. y. The immediate causes of adventitious productions must necessarily vary with their na- ture. In most of them, the constitutional powers are in fault; and, in some, the cause is chiefly lo- cal. Some pathologists have referred them to debility; others, to increased organic action or ir- ritation ; and several, to the perversion of the func- tions of secretion and nutrition. The first and last opinions conjoined will, perhaps, the most nearly approach the truth; for it must be admitted that the perversion of these functions often originates in, or is associated with, debility. Those secretions, however, which proceed from sthenic or phlogistic vascular action, as healthy pus, coagulable lymph, &c, do not fall within this description. With those exceptions, therefore, they may be imputed to that condition of life to which I have already attributed them, viz. to depressed as well as perverted manifestations of vital power (§ 91.). The circumstances, extrinsic and intrinsic, in respect of the frame, under which they appear,— the agency of cold, moist, and impure air, of deficient and unwholesome food, and of the de- pressing passions, in producing them, — furnish strong evidence of the accuracy of this inference. Even as respects those changes which most fre- quently commence with signs of local irritation or vascular excitement or congestion, the general conditions of life, and, consequently, the whole economy, are more or less in fault; and are es- pecially concerned in producing the local change, of which irritation, or any other form of local agent, is merely the efficient cause. 129. S. The terms which have been assigned to the various productions falling under this head, have been sufficiently arbitrary; and a greater desire has been evinced to discover new species, and to impose on them new names, than to view them as they are actually presented to our ob- servation, and without reference to the descrip- tions and opinions of their nature — too often erroneous, and improperly mixed up— that have been given of them. Nor have the arrangements of them that have been attempted been less arbi- trary. Certain of them have been named, from their form, as tubercle; others, from their colour, as melanosis; and some of them, from their re- semblance to healthy structures, as medullary, mammary, encephaloid substances: and they have been variously arranged; as, into such as are products of secretion without organisation, or of nutrition with signs of organisation. It must be evident, however, that the difference is chiefly that of terms; for nutrition is only a modification of secretion. They have also been divided into the encysted and the non-encysted; into the local and the constitutional; and into the inert, or not necessarily noxious, and the malignant, or con- taminating. These distinctions, although very important, are not uniformly preserved; for the same substance may be both encysted, and non- encysted or infiltrated; and the alteration, which is merely local in some cases, may be constitu- tional in others, or become so; and that which may long or always remain inert in some instances, may sometimes be malignant and contaminating from the commencement. Besides, they may DISEASE-—Adventitious Secretions and Productions. 589 originate either in changes in the nutrition of the natural tissues, the adventitious secretion being a consequent lesion; or in the production of new substances, alterations of nutrition being later lesions; or even the secretions, as well as the na- tural tissues in which they are elaborated, may undergo subsequent transformations. So extremely diversified are the causes which induce these diseases; the states of vital manifestation and of vascular action by which they are attended at their origin and in their progress; and so re- markably are they modified in their course by ex- ternal agents and intrinsic states of action; and, moreover, so insensibly do they pass into one another, and so frequently and variously are they complicated; that any arrangement must, neces- sarily be arbitrary, and a choice of difficulties. Reference, however, to the varying characters of the adventitious formations having been had in the articles upon specific morbid structures, and upon the varying alterations which the principal tissues and organs present, I shall here only take a general view of them, in the following order:— 1st, Secretions adventitious to the frame, and devoid of organisation: 2d, Adventitious secre- tions associated with morbid nutrition; or those that are apparently organised, but which depend upon the adjoining tissues for their vitality: and, 3d, Those which become organised, and possess an independent life. 130. A. Secretions adventitious to the frame, and incapable of organisation or vitality.—These substances present no trace of fibres, laminae, canals, or areolae; they are of various degrees of consistency; and certain of them change either from a fluid to a solid state, or from the latter to the former. They consist chiefly of albumen, gela- tine, and the usual salts found in the serum of the blood. The substances that fall under this de- scription are:—1. Pus; 2. Tubercle; 3. Fatty matter; 4. Glue-like matter, or the colloid mat- ter of Laennec ; 5. Melanosis, or black matter; and, 6. Saline ingredients. These may exist either singly, or variously associated. 131. (a) Pus.—This term has been applied to a morbid secretion, whose physical properties vary considerably. That form of it which is usually secreted in a state of the constitution not remarkably depressed or vitiated,is a homogeneous cream-like fluid, of a yellowish white colour, faint smell, and slightly sweetish taste. But it often departs far from this state; and even that which is secreted from the same surface, may be very remarkably changed in a very short period, gene- rally owing to modifications of vital power and vascular action. Sometimes it very closely re- sembles a thick cream; at others a mixture of curds and whey; and at others a turbid serum, or a grumous sanies, or the dregs of wine. Occa- sionally it seems disposed to become solid, and to assume the appearance of tubercle. At one time it is quite inodorous, at another very foetid. Its •colour also changes from white to yellow, from green to red; or this order is reversed. In some instances, it is yellowish green, or yellowish brown, and other related shades. The following are its varieties, according to its physical proper- ties:—1. Creamy, homogeneous, or laudable pus; 2. Curd-like pus; 3. Serous pus, or sero-puriform matter; 4. Muciform pus, or glairy puriform matter, or puriform mucus; 5. Bloodv pus; and, 50 6. Concrete or lardaceous pus. These alterations are chiefly attributable to the texture in which it is secreted, to the degree of local irritation or ac- tion, to the period it has been retained, to the general state of vital energy and vascular action, to the condition of the circulating fluid, and to the diathesis and constitution of the patient. But these varieties often run into one another, showing that any arrangement of the physical appearances of this secretion must necessarily be arbitrary. In the scrofulous diathesis, however, it often pre- sents certain distinctive characters, and inclines nearer to the curd-like variety, or seems more disposed to become solid, from the absorption of its serous portion, when it has been some time shut up. But the most specific differences that exist in pus are not to be ascertained by chemical re- search, nor external appearances. Two portions of this fluid, identical in every respect, will pro- duce very dissimilar effects: when introduced beneath the cuticle, one will occasion merely a slight irritation; the other a most dangerous con- stitutional malady, capable of disseminating itself through thousands. 132. Pus has been found in every tissue, struc- ture, and organ of the body, and in all the vessels, and in the blood itself, both imperfectly mixed, and in the centre of clots. It may exist in the tissues and parenchymatous organs, either col- lected in the form of abscesses, or disseminated and infiltrated through their structure. When formed in muscular, nervous, and even in some other structures, it is in reality furnished by the connecting cellular tissue, which is the chief seat of the inflammatory action producing it. In a great majority of cases, its presence, either in dis- tinct collections, or in a state of infiltration, is ac- companied with signs of irritation or inflammatory action; but instances occur, in which it is attended by no such appearances. The opinion, that it could be formed only where there is ulceration, has been shown to be unfounded: for it may be secreted on the surfaces of membranes, without any breach of continuity; or collected in the parenchyma of the organs, without any appear- ance of inflammation; or infiltrated between the fibres and in the areolae of the tissues, without" any loss of substance. It is met with in the second and last of these forms in the consecutive states of suppuration, or when puriform or sanious matters have passed into the circulation, from distant parts, or from disease of the veins, &c. When the production of pus has been preceded by any degree of vascular irritation, the surrounding tissues present—1st, various grades of injection; 2d, various shades of colouration; 3d, different degrees of softening; 4th, solutions of continuity, which may either have preceded or followed the purulent secretion; 5th, the disappearance of the proper structure of the part, and its degeneration into cellular tissue, in the areolae of which the pus is infiltrated. (For the various distinctive cha- racters of pus, the pathological states which gene- rate it, the symptoms that precede and accompany its formation, and the means of protecting the frame against its contamination, see the articles Abscess, § 7. et seq.; Inflammation, and Sup- puration.) 133. (b) Tubercle especially illustrates several of the pathological inferences stated above rela- tive to the constitutional conditions favouring 51 590 DISEASE—Adventitious Secretions and Productions. the occurrence of many adventitious productions (§ 128.). The history of these formations in the lower animals, and the depressing causes so frequently connected with their appearance in the human subject, would lead me to infer— 1st, That the conditions of life throughout the frame, in tubercular disease, are not merely weakened, but also otherwise modified or perverted, either from original conformation, or from acquired diathesis: 2d, That this state of vital manifest- ation often obtains in connection with tubercles, without any symptom during life, or appearance after death, that can warrant the conclusion that they originate in inflammatory action: 3d, That they sometimes form under circumstances that would lead to the inference that inflammatory irritation is an energetic, although not a neces- sary, cause of their appearance: 4th, But, that local irritation, or that local or general inflam- matory action, can no more account for their formation, than for the production of any other adventitious secretion, without the concurrence of those conditions of life alluded to above (1st); and that, whilst irritation or vascular action does not necessarily excite tubercles, they may occur without the least evidence of irritation: and, 5th, The general conclusion seems to be that the con- ditions of life modify or pervert the functions of secretion in those parts of the frame in which they are developed, and this perversion is often attended by vascular injection. (As to their symptoms, nature, and treatment, see the article Tubercles.) 134. (c) Glue-like, or gelatiniform matter, or colloid substance. — Whilst pus and tubercle are chiefly composed of albumen, with varying pro- portions of water and salts, this secretion consists principally of gelatine. It is sometimes colour- less, but it also occasionally presents shades from a yellow to a pale rose tint. It is without any trace of organisation. It is either infiltrated in the areolae of the tissues, thereby altering very much their appearances; or it is collected in one or more masses, which slightly condense the sur- rounding structure. When infiltrated into the cellular tissue, it generally indurates this tissue, and constitutes a variety of scirrhus. M. An- dral states, that whether the induration is a true hypertrophy of the cellular fibre, or merely the result of mechanical condensation, the jelly-like substance is always traversed and divided into compartments, by numerous, white, hard, resist- ing plates, which seem to secrete it. Sometimes these plates pass into the fibrous or cartilaginous state; and red vessels have been observed rami- fying on their surface, but have never been traced into this peculiar substance. It has also been found in tumours composed either merely of cellular tissue in a state of hypertrophy and induration, or of a variety of morbid products. It is often contained in serous cysts, which ap- pear to have secreted it. When existing in this last form, it constitutes the tumours or cysts called melicerous, from the semblance of their contents to honey. It may thus be secreted in the different tissues in either an infiltrated or an encysted form. 135. (d) Fatty substances may be secreted in different parts of the system in two forms: 1st, that which is similar in every respect to the fat of the body; and, 2d, that which is in some respect or other different from it. The first variety has been noticed under the head of trans- formed secretions; the second differs in appear- ance from the natural fat. Cysts of various sizes contain, either alone, or with several other organised substances—as bone, hair, fibrous struc- ture, &c. — a matter resembling suet. These cysts are found in several parts of the body, but most frequently in the ovaries. The parenchymatous organs may have their proper tissue atrophied and replaced by a fatty matter, forming the fatty degeneration of modern authors. 136. (e) Melanoid and other colouring matters have been secreted in almost every part of the body. (For its nature and pathological relations, seethe article Melanosis.) The golden yellow tinge, sometimes observed in spots, or generally [ diffused, in foetal bodies and new-born infants, constituting a variety of what has usually been called jaundice of this class of patients, has been ascribed to a peculiar secretion, called cirronosis j (xiqoo:, yellow) by Professor Lobstein; but it is probably nothing more than a modification ! of the colouring principle of the bile secreted I under circumstances described above (§ 108.). 137. (/) The saline substances usually exist- I ing in all the fluids of the body are sometimes I secreted in uncommon superabundance in various parts. But besides these, others, not generally found in the fluids, are secreted; and are found, 1st, in the reservoirs and excretory ducts, through which the secretions, in which they have been | formed, pass out of the system, as in cases of salivary and urinary calculi; 2d, in the cellular tissue and parenchymatous organs, either alone, or combined with other morbid productions; and, 3d, replacing other morbid secretions — tubercles being sometimes succeeded by calcareous con- cretions, &c. 138. B. Morbid secretion associated with morbid nutrition, or secretions susceptible of organisa- tion. — This class of productions, in addition to a small proportion of the constituents of unor- ganised secretions, contain a large quantity of fibrine. M. Andral supposes that a small por- tion of this substance, either coagulated in the blood-vessels, or extravasated into or upon the tissues, is the original source whence the or- ganised productions are formed; the fibrinous deposit presenting the appearance of a whitish or reddish mass, of variable consistence, and having a tendency to become organised, although at first possessing neither organisation nor vitality. But I believe that all fibrinous exudations have a certain degree of derived vitality, disposing them to organisation, particularly when they con- tinue in contact with the part that produced them. This pathologist considers, that a portion of fibrine may, when coagulated, indicate its vitality without presenting any blood-vessels or any determinate texture; in which state it may be compared to a zoophyte, which performs a certain grade of vital function, although destitute of a circulating system: and that the fibrinous mass, when impregnated with life, becomes the seat of various organic actions; has a tendency to assume the form of some one of the simple or compound animal textures; performs the I functions of secretion; and exhibits the same morbid phenomena, when irritated, as the natural tissues do under similar circumstances. He fur- DISEASE — Adventitious Secretions and Productions. 591 ther supposes that several tumours, the origin of which has hitherto been mistaken, may be traced to the solidification of fibrine in the blood-vessels of the part; and adduces cases, from the minute dissection of which, he infers, that many of the adventitious productions usually called cancerous, sarcomatous, enceplialoid, and medullary are en- tirely formed in this manner; the minute vessels — arterial, capillary, and venous — being filled with solid fibrine deprived of its colouring matter. It appears, however, much better established, that the latter especially of these productions are formed chiefly of coagulated or altered fibrine, thrown out of the blood-vessels owing to their perverted action, and either collected in masses, into which blood-vessels are produced, or infiltrated into the tissue of the part, the vas- cularity of which is increased along with the alterations that supervene in the adventitious formation and its containing structure. 139. It may be stated of orgauisable products generally,—1st, that they seem chiefly to proceed from the secretion or formation, by the morbid state of the vessels,— frequently depending upon a morbid condition of the frame,—of a certain sub- stance very nearly resembling coagulated fibrine deprived of its colouring matter; 2d, that this substance, from participating to a certain extent in the vitality of the structures in which it is lodged, and from the state of organic action in the parts which formed it, has circulating actions and vessels extended to it, and thereby becomes organised, and capable of performing a certain grade of function; 3d, that it is at the same time transformed into tissues, either similar to the natural textures, or entirely different from them, but equally organised and endowed with life. I shall next notice in a very general man- ner—1st, Organisable products arising from sthenic inflammatory action, and not necessarily depending upon a perverted or morbid state of the constitutional powers; and, 2d, Those adven- titious productions, which not only originate in some constitutional vice, but which also increase both the local lesion and the vitiation of the cir- culating fluids and living solids. 140. 1st. Adventitious structures consequent upon sthenic inflammatory action.—(a) Organ- isable matter, of a fibrinous or fibro-albuminous nature, is frequently formed on serous surfaces, and is generally termed, in its unorganised state, coagulable lymph; and in its organised form, false membranes, cellular adhesions, &c, from its dis- position to assume the appearance of serous and cellular tissues. That these adhesions or pro- ductions may be absorbed, and almost or altoge- ther disappear, if the constitutional energies con- tinue impaired, is established by the observations of MM. Ribes, Dupuytren, Villerme, and Andral, as well as by my own experience. And I believe, moreover, that they may become more fully developed, and assume progressive alterations, when the vital powers are reduced or perverted. (As to the manner in which they are formed, and their progressive changes, see the articles Inflammation and Membrane.)—(b) The* fibrinous exudation sometimes formed on the internal surface of the blood-vessels, and obstructing them, and ultimately causing their obliteration, is in most respects similar to that produced on serous surfaces; the chief difference is in its influence in attracting the fibrine of the blood, and in the consequent results. (See Arteries and Veins.)—(c) A coagulable mat ter, more albuminous than that formed on the surface of serous membranes, is sometimes se- creted by mucous surfaces. I believe that it is merely a modification of the transformed exhala- tion noticed above (§ 106.), and proceeding from inflammatory action affecting chiefly the exhaling vessels of the mucous tissue, and transforming the fluid usually given out by these vessels to a fibro-albuminous state; the morbid exhalation concreting in the form of a false membrane upon the inflamed surface, owing to the evaporation or absorption of its vvartery parts. — Its organisation has been a matter of dispute with French and German pathologists. M.Guersent states that he has seen vessels ramifying in the false mem- branes of croup, and anastomosing with those of the mucous surface. (See Croup, § 36.; Inflam- mation, and Membrane.) — (d) The internal surface of serous cysts may become inflamed and form coagulable lymph, and thereby give rise to further results; — 1. merely to false membranes lining their cavities; 2. to lymph agglutinating their opposite surfaces, and gradually causing the obliteration of their cavities. This latter change often occurs in the cysts formed around coagu- lated blood, particularly when extravasated in the parenchyma of organs. — (e) The adhesion of divided structures takes place in consequence of the effusion of coagulable lymph, which be- comes organised, and passes from a cellular to a fibrous state, and ultimately becomes identified with the tissues it unites. 141. 2d. Adventitious productions, depending upon constitutional vice, as well as upon perverted organic action in their seat, may be divided into two species — the consecutive and the primary— the former commencing in carcinoma, the latter appearing at once in the true cerebriform or hamato-cerebriform states. The former is the connecting link between carcinoma, or hard cancer, and the cerebriform disease. They both have certain points of resemblance,— secretion and nutrition being perverted in both; adventi- tious productions, and subsequent destruction of the affected tissues, taking place in both; and both being attended by a perversion of the con- ditions of life, and an increasing contamination of the circulating fluids and living solids. Their chief points of dissimilarity are referrible espe- cially to the manner in which the former ori- ginates. It occurs, like the transformations in which it begins, in certain parts or tissues in preference to others, and only at mature or ad- vanced epochs of life; commonly commencing locally, and but rarely simultaneously in different parts of the same tissue, or in different structures and organs, however frequently affecting both the one and the other successively.— The latter, or primary, is met with chiefly at the early epochs of life; it attacks any texture or viscus, either simultaneously or successively, and at once appears as a soft, tumefied, spongy, pulpy, or cerebriform structure, or in some one of its modi- fications (§ 142.). 142. The consecutive species only sometimes occurs in the advanced course of scirrho-caucer, which usually commences in certain of the states of morbid nutrition and secretion noticed above, 592 DISEASE—Adventitious Si especially in hypertrophy or condensation of the cellular and allied tissues, with a perverted se- cretion, and deposition of a firm, grey, semi-trans- parent substance in its areolae, and without any specific boundary between it and the healthy structure, in some cases; or with a more distinct demarcation, and a regular or lobular formation, in others; or with the secretion of a purely gelatinous substance in minute masses, or in the areolae of the tissue (§ 134.); or, lastly, with a uniform infiltration of a more albuminous and lighter coloured matter in the texture of the part, giving rise, respectively, to the different varieties of scirrhus. But these hard, grey, or gelatini- form, or lardaceous alterations, are generally softened, liquefied, ulcerated, or even partially destroyed, and have thereby passed into the car- cinomatous state, before the adventitious produc- tion makes its appearance in any of the forms about to be noticed. Thus, scirrhus passes into carcinoma, or open cancer; and this latter, in rarer instances, into some one of the varieties which the cerebrifom malady presents. 143. The primary species is very varied as to its colour, figure, size, and consistence. Some belonging to it have a homogeneous structure, resembling coagulated fibrine deprived of its colouring matter, and are of different degrees of hardness, occasionally approaching to cartilage, and sometimes being almost semi-fluid, or resem- bling putrefied brain. Others of these produc- tions are composed of substances which are variously constituted; their structure being fila- mentous, or areolar, or cellular, or both cellular and lobular, generally with numerous canals or cavities containing different kinds of fluids. In all, there is an admixture of solids and fluids in various proportions; the latter being either colourless, resembling serum, or more or less coloured, or altogether fluid blood. This struc- ture may be so arranged, as to constitute either of the varieties of sarcoma, especially the mam- mary and medullary of Abernethy; or it may, owing to its softness, the delicate nature of its vessels, the tendency to haemorrhagic infiltration, the rapidity of its protrusion through its ulcerated coverings, and to the occasional bleeding from its surface, form the true fungus hamatodes of several modern writers. When it assumes this last appearance, it is more or less coloured, either in parts, or throughout, from the admix- ture of fluid or coagulated blood, collected into small circumscribed masses, or infiltrated into portions of its tissue. (See H^mato-cerebri- form Disease.) 144. It may be remarked generally, respecting all the forms of organic change characterised by the deposit of either an unorganisable or organisable substance, that the specific matters entering into their composition have been de- tected in the lymphatics, in the glands, and in the veins proceeding from the diseased part. Pus, tubercular matter, melanoid matter, cerebri- form matter, &c. have all been found in these situations; the consecutive appearances of the disease in other parts being thereby explained, even although — in respect of certain of these maladies especially — it may also occur in more than one part, coetaneously, owing to the dia- thesis, or general condition of vital manifestation; and prcrioosly to the absorption of any portion CRETIONS AND PRODUCTIONS. of the morbid deposition, and to its consequent softening or destruction. 145. C In respect of those productions which are not only organised, but ivhich possess an inde- pendent life, and which constitute the Entozoa, I shall add but little to what I have stated else- where. They are found in all animals, either in the cavities, or in the parenchyma of organs: each of them having its special habitation — the fasciota hepatica in the liver, the filiaria in the cellular tissue, the strongylus in the urinary pas- sages, and the ascaris lumbricoides in the intes- tines. They may be divided into three orders; the vesicular, the flat, and the cylindrical. Their organisation varies from a parenchymatous mass, or a cyst containing a limpid fluid, but without appendices, to that provided with one or more appendices, or with an evidently organised head; from this state, to a regularly formed structure, consisting of muscular fibres and an alimentary canal; and, ultimately, thence to a fully de- veloped animal, possessed of sexual organs and the rudiments of nervous and circulating systems. LinnjEus arranged the entozoa into the intestinal and the visceral. Rudolphi divided them into five classes, according to their form. Cuvier classed them into two orders; the parenchyma- teux, or those without any alimentary canal, and the cavitaires, or those possessing a digestive cavity. This last arrangement will be followed; inasmuch as in the article Hydatids will be noticed all those comprised in the parenchyma- teux of Cuvier, and under Worms those belong- ing to the cavitaires. 146. As to the origin of the entozoa, much difference of opinion has existed, chiefly among German, French, and Italian writers. In respect of the first of the classes, viz. hydatids, little doubt can exist; but in respect of those that lodge in the intestinal canal, the case is otherwise. The subject, however, is sufficiently discussed in the articles referred to. But there is one important fact, which holds good in respect of the gener- ation not only of hydatids and worms, but also of all adventitious productions and depositions; and which should not be lost sight of in devising means for their prevention and permanent re- moval, viz. that whatever depresses the mani- festations of life throughout the frame — more especially those of healthy secretion and nutri- tion— will both favour their developement, and their increase or extension. These morbid form- ations may be even produced at will, by whatever lowers the vital energies; — by cold, moisture, unwholesome air and food; by a watery, vege- table, or impoverished diet; by the depressing passions; by exclusion of ligbt or sunshine, &c; — and not only may they occur singly under these circumstances, but they may also be com- plicated with various other maladies, of a con- stitutional or local kind, the nature of which may be thereby so far modified as to require a different treatment from what would be required in ordinary cases. Thus, complications of fever or of visceral inflammations with intestinal worms, are often the ultimate effects of long-neglected states of debility, and require less lowering mea- sures than under other or usual circumstances, as well as differently appropriated remedies. Are we to suppose that, whilst the human ceconomy is under the influence of the depressing causes DISEASE — Connection between A noticed above, the organic molecules are thereby ' prevented from being so perfectly assimilated, or so highly animalised, and indeed vitalised, as in health; and that, the vital attraction requisite to ' due nutrition being weakly or insufficiently ex- erted, they proceed to arrange themselves, ac- ] cording to the grade of vitality they possess, into much inferior beings in the scale of creation? 147. vi. Of Destruction of organised Pa r ts.—This may take place in thre e ways:— 1st. By interstitial absorption, by means of which the J partis first atrophi'.d, and afterwards altogether re- j moved; — 2d. By superficial absorption, or ulcera- tion, which may be consequent on inflammation, or may proceed from the pressure of adjoining parts, and from loss of vital cohesion in circumscribed por- tions of membranes or superficial tissues; —3d. By mortification, owing to intense grades of inflam- mation, either absolutely or relatively to the state of local or general vital energy,— to a destruc- tion of the nervous influence of the part,— to in- terruption of the circulation from disease of the vessels,— to pressure impeding both nervous power and vascular action, — and to generally depressed vital power, associated frequently with a morbid condition of the blood, and sometimes with diseased blood-vessels, or with external pres- sure: hence the readiness of the occurrence of any of the forms of mortification in old age-, during dynamic and exanthematous fevers, from erysipelas, from deficient or unwholesome food, and from syphilis or mercurial cachexy; — and 4th. By the softening and swelling arising from the greatly diminished or lost vital cohesion of cellular and adipose parts, and their infiltration with a serous fluid (comprising the Noma, or watery cancer, of authors ) giving rise to a form of disorganisation different from the foregoing, that often passes rapidly into a state of jelly-like solu- tion and gangrenous erosion, particularly in the lips, cheeks, and genitals of children. A similar destruction sometimes also takes place in the stomach; and the true softening of the brain, in its extreme states, seems to be of the same nature. This species of disorganisation is intermediate between ulceration and gangrene. (See Atro- phy, Cellular Tissue, Gangrene, Soft- ening, and Ulceration.) 148. V. Connection of Morbid Actions and of Organic Lesions with States of the Blood.—Depressed and perverted states of vital power have been shown to be often connected with a deficiency or vitiated state of the circulating fluid, in chronic and cachectic diseases, and with excrementitious plethora, or the accumulation of the constituents of the various secretions in the blood in the early and advanced stages of fevers. (See Blood, and Debility.) Primary excite- ment, in either its local or general forms, is often caused, or atleast favoured, by vascular plethora; and reaction, or secondary excitement, with local determinations or inflammatory action, is fre- quently produced by this condition, existing either absolutely or relatively, or associated with the accumulation in the blood of the constituents of the secretions and excretions, owing to the interruption of these functions, as in the stage of reaction in fevers (§ 85.). 149. The connection of the lesions of secretion with the states of the circulation is one of the most important topics in pathology, and has 50* lterations of Fluids and Solids. 593 therefore been noticed in this (§ 95. et seq.) and other articles. The superabundance and trans- formations of one or two of the natural secretions are sometimes owing to the alteration, interrup- tion, or suppression of others,— to the derange- ment of the balance of healthy action, and to the consequent plethora or vitiation of the circulating mass. Thus, morbid states of the cutaneous or of the intestinal secretions are often caused by inactive function of the kidneys or liver; and alterations of the urine, or of the bile, are fre- quently produced by suppression of the perspi- ration, or of the secretions from mucous surfaces. Morbid increase of the exhalations, particularly those poured into serous cavities, or into the areolae of cellular parts, is, in many instances, connected with general plethora, as well as with local conjestions, and deficient excretion; whilst the transition of conjestions into inflammations, and the transformation of these exhalations into a fibrinous or fibro-albuminous substance, by sthenic inflammatory action, are promoted by the abund- ance of this constituent in the blood, and the general exuberance of this fluid. When the re- crementitious secretions are imperfectly elabo- rated, owing to depressed vital power, the func- tions of chylifaction, sanguifaction, nutrition, and depuration are also impeded; the usual results being insufficient excretion, an impure state of the blood, and ultimately slow irritative fever, marasmus, anaemia, and other chronic diseases. In such cases the morbid phenomena proceed in a circle, or rather act and react upon each other, either until vascular excitement is produced by the state of the circulating fluid, and the secreting and excreting functions are thereby restored, as shown in the article Crisis (§ 15.), or until some organic change supervenes. If we attempt to trace the procession of morbid actions, we shall often find that depressed vital power affects the secretions subservient to sanguifaction; these modify the quality, and ultimately the quantity, of the blood; the altered condition of this fluid disorders the vascular actions and depurating functions, whilst it further deranges the nutritions secretions; and thus the evil continues to increase until the living solids become changed, and inca- pable of performing their prescribed actions. 150. In connection with the various lesions of nutrition which have been brought into view, the blood can seldom long retain its healthy state. But the change is evidently, in the first instance, that of quality rather than of quantity, although it is very difficult to show in what respect the quality is modified. Excessive excretion and discharge will often, however, sensibly diminish the quantity of this fluid before any other change either in it or in the functions of nutrition becomes apparent. Local alterations of secretion and nu- trition conjoined, whether originating in the organic nervous influence of the part, or in the quality of the blood circulating through it, ulti- mately change both the one and the other, and generally in a way that cannot be mistaken. In many instances the alteration of the blood is evi- dently owing to the absorption of the molecules which had been deposited, secreted, or combined in the morbid structure, and removed in the usual course of that transition of the solids into fluids, which obtains in the living economy, equally with the transition of fluids into solids. Animal 594 DISEASE — Procession of Morbid Phenomena. organisation is the complement of a process of combination and decomposition,— of attraction from, and dissolution into, the blood, of the con- stituents of the various tissues composing it; and if, in the former part of the process, the elements form heterogeneous productions, the dissolution of these productions, and commixture of their molecules in the blood, must necessarily vitiate both it and the structures through which it circu- lates. Accordingly we find, even in fevers, that the rapid absorption of a large portion of the molecules of the simpler or primitive tissues alters the circulating fluid often in a very evident man- ner; diminishes the density, cohesion, and bulk of many of the soft solids; and changes, at the same time, the colour, and other sensible proper- ties, of both fluids and solids, to a remarkable extent. But as this resolution of a portion of the constituents of the textures into the fluid state, in fevers, generally takes place without any pre- existing adventitious formation or malignant pro- duction, the absorbed materials admit of removal by the emunctories without permanently contam- inating the frame, or being deposited in various tissues or organs, and thereby increasing and ex- tending the mischief. 151. In case of chronic alterations of secretion and nutrition, giving rise to various adventitious productions, whether local, constitutional, or malignant, the dissolution of the modules that must necessarily take place (conformably with the law of organisation stated above ( § 150.), if they be organised ; and owing to the irrita- tion of the surrounding tissues, and consequent secretion of a fluid matter which dissolves them, and prepares them for absorption, if they be con- crete and unorganised), and the passage of these molecules into the blood, will first vitiate it, and next diminish its quantity; at the same time that such of the molecules as are not quickly dis- charged by the emunctories from the circulation, will be deposited in other parts of the frame, forming consecutive productions of a similar nature. The consequences, therefore, of various local alterations of secretion and nutrition — as of pus, tubercle, carcinoma, &c.— will be,— 1st, As respects the absorbent system — (a) the presence of a portion of the molecules of these productions in the absorbents proceeding from the parts in which they are formed ; (6) irritation of these vessels, excited by the morbid molecules, especially where they ramify and reunite in the glands ; (c) the accumulation of the morbid matter in the absorb- ents, or its deposition in the glands themselves : 2d, As regards the blood and vascular system — (a) the passage of the morbid molecules into this fluid, either directly by the veins, or more cir- cuitously by the absorbents, or by both channels; (6) the contamination of this fluid; (c) consequent irritation or inflammation of the blood-vessels ; (d) an imperfectly assimilated or deficient quantity of blood, owing to disorder of the recrementitious secretions, and of the functions of chylifaction and sanguifaction : and, 3d, As respects the soft solids — (a) the deposition of the morbid mole- cules in the areolae of the cellular tissue, or the infiltration of them into parenchymatous organs; (b) their secretion on the surface of serous mem- branes, or shut cavities, as those of the joints or bursoe ; (c) their excretion on the mucous and cutaneous surfaces, with inflammation, softening, I ulceration, &c. of these surfaces, or of their follicles; (d) their excretion by glandular organs, either with or without inflammation and disor- ganisation of those organs. 152. VI. Of the Procession of Morbid Phenomena.— i. The Stages of Diseases have been variously divided by pathologists. Some wri- ters admit only three periods, viz. the increase, the acmi, and the decline; whilst others enumerate five, six, or even seven. The three stages now mention- ed are sufficient to distinguish the principal changes of disease generally; but in respect of febrile diseases *, they may be subdivided with advantage. A. Thefirst or inc re mental stage consists of— (a) theprecursory period, or the time that elapses from the impression of the exciting cause until the disease forms, or manifests itself in an evident man- ner. The characteristics of this period are generally languor, a diminution of the usual physical and men- tal energy, a weak or slow pulse, or irregular ac- celerations of pulse, slight chills, alternating with flushings or heat of skin; change in the coun- tenance ; and weakened power of the digestive, secreting, and excreting functions. In many in- stances, little or no complaint is made; or, at most, only a slight malaise, or indefinite feeling of indisposition, indicative of depression of the vital energies. This period is of very variable duration — from a few hours to two or three weeks — and is the same with the " stadium opportunitatis " of Hildenbrand, the " latent period " of Dr. Marsh, and the period of "in- cubation" of the French pathologists.— (b) The formative period, or that of manifest invasion, comprises the time from which the commence- ment of the disease is usually reckoned, and criti- cal evacuations expected. It is frequently at- tended by convulsions in young children ; by syncope in females ; and by chills, rigors, sickness or vomiting, pain, &c. in all classes of patients. These symptoms are generally accompanied by others, having a more especial reference to the nature of the disease which they usher in: as by aching pains in the head, loins, and limbs, in fevers; by acute pain and difficulty of breathing, in pleuritis ; by vomiting, constipation, and pains about the umbilicus, in enteritis, &c. ; and seldom continue longer than some hours.— (c) The period of developed excitement, or of reaction, or — if this pathological condition is not prominent — of aggravation of the chief symptoms : in which the pulse becomes quicker, fuller, and harder than in the former periods ; the func- tions of digestion, assimilation, secretion, and excretion more or less impeded ; the animal tem- perature and thirst commonly increased ; and the tongue coated, &c. This period may continue only a few hours ; or be prolonged to as many days, or even weeks, in sub-acute or local diseases. The whole duration of this stage is extremely various ; but is usually much shorter in febrile than in local and organic diseases.—B. The second stage, or the acme, consists — (a) of the period of stationary reaction, in which the symptoms, having reached their height, remain in this state * This division of the periods of fevers, and an abstract of my opinions of their pathology, taken from my Lec- tures delivered from 1824 to 1829, was published in the London Medical Repository for Sept. 1827, p. 238. I state this, as similar views have been promulgated by others subsequently to this last date. DISEASE—Type or Form of. 595 for an indefinite time — varying from a few hours to several days, weeks, or, in local maladies, even to some months—presenting slight modifications and vacillations, tending either to a favourable or unfavourable termination.— (b) Of the period of crisis, in which new phenomena appear, indi- cating either a salutary or fatal issue. The whole duration of this stage is, in febrile diseases, ge- nerally shorter than that of the first; but there are numerous exceptions to this rule.—C. The third stage, or that of decline, consists— (a) of the period of decrement, or exhaustion, in which the symptoms subside more or less rapidly, and the vital organs begin to resume their functions, in favourable cases; or the energies of life to sink, in those of an opposite tendency. — (6) Of the period of convalescence, in which the remaining traces and consequences of the malady disappear, and the vital and animal functions regain their healthy condition and balance. 153. There may be some doubts of the pro- priety of adopting certain of the above sub- divisions, as they are chiefly applicable to febrile diseases ; but they likewise obtain in some other maladies. In those in which they are less re- markable— namely, in organic diseases — any division into stages can seldom be adopted with advantage, or be made otherwise than in an ar- bitrary manner. In these maladies, and, indeed, in some others, the second or formative period of the first stage may not be manifest; nor the second, or critical period of the second-stage ; and many may question the propriety of making convales- cence a period of the disease. But I believe, that, during the restoration of the various functions, there still remain certain pathological states or degrees of disorder, requiring the attention of the practitioner ; and, in many instances, a marked tendency to relapse upon exposure to the exciting causes of the malady. For pathological reasons, therefore, as well as on account of the future health of the patient, convalescence should be always treated as a period of disease. 154. ii. Grades of Action.—The terms active and passive have been much employed in pa- thology, and often without regard to precision. They should have reference only to the kind of vital action characterising disease, and not to its duration ; with which, however, they have been too frequently confounded. Thus the term active has been often employed synonymously with acute, and passive with chronic. But, although an active disease is generally acute, it is not so always or necessarily, and may even be of a chronic duration ; whilst the most pas- sive maladies, as respects the grade of vital ac- tion, may be most acute with reference to their continuance. It should never be overlooked, in our appreciation of pathological conditions, that medical terms are only conventional or ar- bitrary signs, employed, often too indefinitely, to convey our ideas of certain ever-varying con- ditions of vital manifestation and organic change; and that, in using the words active and passive, we should restrict them entirely to the expression of grades of vital action, and view them as pos- sessing an arbitrary as well as a relative import, inasmuch as there is every intermediate degree between the most active and the most passive states of disease. 155. iii. Of the Type or Form of Disease.— The type is the order of succession observed to obtain among certain morbid phenomena ; and admits of modification from various causes, with- out the intrinsic nature of the phenomena being essentially affected. It has commonly been divided into the periodic and the continued; the former being subdivided into several specific forms. — A. Of the periodic type, and the periodic i city of morbid actions.—The intermissions or re- missions of morbid phenomena, and their return or exacerbations after regular or nearly regular periods, constitute their periodicity; and are characteristic features of a number of diseases. These features are, however, more or less modi- fied and marked in certain maladies than in others, in respect both to the paroxysms or accessions of morbid action, and to the intervals which separate them; and hence periodic maladies admit of va- rious modes of arrangement, of which, however, | that into the febrile and non-febrile (pyrexial and i apyrexial) seems to be the preferable. The form- er are characterised by the regular stages of febrile action which the paroxysm presents in most in- stances, and the definite duration of the intervals or remissions: the latter are remarkable for the suddenness of attack, and their evident dependence upon, and affection of, the nervous system ; as well as for the less regularity of their intervals. Of the various modifications, which these two classes of disease present, sufficient notice has been taken in the articles on Fevers, and on the nervous disorders which possess this feature, especially Asthma, Epilepsy, Hysteria, and Neuralgic Affections. 156. The cause of the periodicity of many diseases has never been satisfactorily assigned. Some have imputed it to the daily alternation of the erect and supine postures; others to the action of light, or, in other words, to solar influence. There is a certain tendency to periodicity in almost all diseases, in which the nervous functions are more or less affected, and even in convalescence: the remissions being often scarcely perceptible, and the exacerbations generally assuming the tertian type. The periodicity of morbid actions cannot be explained otherwise than by referring it to a law of the animal economy; and, as those maladies, in which the nervous systems are pri- marily and chiefly affected, are most remarkably periodic, we may infer that it is especially de- pendent on these systems. This law obtains to a certain extent in health, as respects the perform- ance of many of the vital functions; its existence in disease, in a more evident or modified form, should not therefore be a matter of surprise, par- ticularly when the functions of those systems on which it is more immediately dependent are prin- cipally affected. It is most distinct, and the intervals most complete, in maladies consisting especially of disturbance of the organic and ce- rebro-spinal functions, and in those in which the excretions are not much impeded, and the blood consequently not materially altered from the healthy state, or where the other causes to which the continued type is attributed (§ 157.) do not exist. 157. B. The continued type consists of an un- interrupted succession of the morbid phenomena, from the irruption of the disease to its termination. Some maladies present a nearly regular intensity during their course, and have therefore been called 596 DISEASE — Duration of Morbid Actions—Terminations. by the older writers " morbi continentes." Others evince slight morning remissions, with exacerba- tions in the afternoon or towards evening : others, in addition to these, experience some degree of exasperation on certain, most frequently on alter- nate, days; and others, as some kinds of fever, as- sume at first a remittent form, but soon become continued, and at last again slightly remittent dur- ing convalescence. Even the more strictly contin- ued febrile diseases evince a remitting or periodic type, in some degree, during decline or early conva- lescence. It would seem that a marked tendency to periodicity exists in all diseases, and that the continued type is imposed — (a) by a high degree of inflammatory action; (6) by impeded or inter- rupted secretion and excretion, and consequent alteration of the quality and quantity of the circu- lating fluid. Thence it may be inferred, that the type will be the more evidently continued, the greater the pathological states to which I have chiefly imputed it; and that, as in respect of other medical terms, continued or periodic are usually employed in an arbitrary manner, — the one type passing into the other, the regularly periodic and the continued forming the extremes of the scale, between which there is every grade, ascending from the former, or regularly intermittent, through the less perfect and the remittent, until the con- tinued is reached. 158. iv. Of the Duration of Morbid Actions.— The period intervening between the actual irrup- tion and the termination of disease is of very va- rious length. Haemorrhages sometimes continue only a few minutes, cholera a few hours, whilst asthma, rheumatism, and gout, may remain the greater part of life. Some maladies, originating in infection, have a specific duration, as small- pox, measles, typhus, &.c. If we calculate from the time when the exciting cause made its im- pression, many diseases, whose length often ap- pears definite, will present a much less uniform character. Thus, in plague and other pestilen- tial maladies, the effluvium from the sick has sensibly affected the healthy, and terminated ex- istence in a few hours from its impression, whilst other persons have not been seized by the fully formed malady until many days after exposure to its cause. Marsh miasmata have, in some instances, not produced ague until several weeks after their impression was made on the frame; and the rabid virus has sometimes not occasioned its dreadful effects until many months after its inocu- lation. If we comprise the time that elapses from the first manifestation of functional disorder, to its termination from fatal organic lesion, the dur- ation of numerous diseases will not infrequently form no mean portion of the usually allotted period of existence. Some maladies of a slight and febrile kind, depending upon disturbance of the stomach or bowels, occasionally subside in a few hours, or in a day or two, and from this circumstance have been called ephemeral. 159. A. The terms acute and chronic are very arbitrarily employed to designate the duration of morbid actions ; and, owing to the circumstances of their being often used as general but loose characteristics of disease, they have been mis- taken by the inexperienced as indicating the existence of two forms, between which there is none intermediate. To this misconception me- dical writings have contributed, chiefly by de- scribing merely these two conditions as simple and unvarying forms, instead of considering them as arbitrary signs employed to indicate the more extreme states, in respect of duration, between which there may exist every intermediate degree. Many employ these terms, to express not only the duration of morbid action, but also its grade or intensity. Of this little need be complained, if the meaning attached to the words be pre- viously assigned. Numerous writers, impressed with the vague manner in which these appella- tions have been used, have endeavoured to give them a greater degree of precision by adjoining qualifying epithets to them. — (a) Diseases have been generally viewed as acute, when they are not prolonged beyond forty days; some writers subdividing those thus characterised, into the ': most acute," when they terminate in three or four days,—into the " very acute," when they do not continue longer than seven days,—into the " simply acute," when they endure for fourteen days,—and into the "sub-acute," when they reach forty days. — (6) Maladies which are pro- longed beyond the last term have been usually designated chronic ; but they hardly admit of a similar subdivision to the above, their duration being indefinitely prolonged. The subdivision of them into functional and organic, if the dis- tinction could be made during life, would be of practical importance ; but, although it might be made in diseases of some organs, it cannot so readily in respect of others: besides, most chronic ailments are first functional, and so gradually and imperceptibly run into organic change, that no line of demarcation can be drawn between the two states. 160. VII. Of the Terminations of Dis- ease.— Morbid actions end ultimately in two ways: 1st, In health; 2d, Death. But before termi- nating in either, they may assume other forms, or altogether distinct characters; giving rise to what may be called the succession, the transition or conversion, and the metastasis of disease. — A. The return to health consists in the restoration of all the functions. It takes place in ways pecu- liar to the nature of the malady, and consequent- ly in very diversified modes. — (a) In local dis- eases, and in those simple pathological states con- sisting of debility, excitement, exhaustion, &c, the terminations in health are the most direct. Nervous affections and haemorrhages commonly end by the mere cessation of the phenomena of which they consist; and a similar occurrence obtains in respect of simple congestions and various functional complaints, as jaundice, dis- orders of the stomach and bowels, &,c. In the restoration, however, of inflammations to the healthy state, the changes are more numerous, the various phenomena of which this lesion is composed either disappearing in succession and gradually, that is, in resolution; or giving rise to other alterations of a more or less serious or dis- organising kind ; and these to new secretions and states of nutrition, as purulent collections, ulce- ration, sphacelation, and ultimately to the pro- ductions of coagulable lymph, granulations, and cicatrisation. — (b) In febrile and constitutional maladies, the return to health is generally the result of a series of changes in the economy, however rapidly it may take place ; and is usu- i ally characterised, first, by the subsidence or DISEASE — its Relations, Successions, and Complications. 597 exhaustion of the morbid state constituting the chief pathological condition, and, second, by the restoration of the secreting and excreting func- tions, the interruption of which constituted one of the chief features of disease. (See Crisis.)— (c) In organic lesions, the restoration of the health is less frequently effected, either by nature or by art. than in the preceding classes of disease, and is usually the result of modifications of the secretions and nutrition of the part different from those in which the organic alterations originated. Consequently the return to the natural structure is generally slowly, and often only partially, ac- complished,— is always aided by a due mani- festation of the vital energies and performance of the secreting and excreting functions, — and is frequently favoured by irritation of, and derivation to, some remote tissue or viscus, occurring spon- taneously or excited by art. 161. In all diseases, the restoration to health is as much owing to the vital energy, as to subsidence of the particular morbid actions which constitute them. Thus, acute or sub-acute inflammations occasion various changes of structure; yet the mere disappearance of the inflammation does not con- stitute the return to health. The organic lesions still continue; but these are ultimately removed in the course of that constant process of attraction from, and dissolution into, the blood, of the special molecules of the tissues. Secretion and nutrition have been shown to be not the mere deposition of organic particles, but a constant circulation of these particles from the blood into various fluid and solid forms, and back again into the blood, after having retained these forms for a longer or shorter period: and, as the organic molecules are identified with the various structures, in virtue of the vital influence and attraction which actuate these structures, it follows that the more this in- fluence is exerted, the more will nutrition be per- fected, and any aberration from the healthy form avoided and restored. Consequently, in the course of this process, the natural type of formation will be preserved, and any morbid production be re- moved. — (a) Various phenomena (critical chan- ges) of a very marked character indicate the ter- mination of acute diseases in health; and have received, from their importance, the attention of physicians. (See Crisis.) — (b) As the functions become re-established and the pathognomonic symptoms subside, and at last disappear, so the de- cline of disease passes into convalescence, in which, at first, more or less of the phenomena constituting the disorder, and of debility, not merely of the or- gan chiefly affected, but also of the rest of the frame, still remain; the functional or the organic lesion gradually disappearing as the manifestations of life throughout the system become more and more developed, or attain their healthy state and balance. (See Debility, § 43.) 162. B. The termination in death takes place in various ways, both in acute and chronic diseases. It may occur in the former more or less suddenly — (a) from rapidsinking of the vital powers, as in adynamic fevers; (b) or from fatal haemorrhage before exhaustion has reached its utmost, as in some diseases of the lungs and digestive canal; (c) or from pressure on, or interrupted circulation through, the brain, accompanied with convulsions, or coma, or with both, as in various diseases of this organ; (d) or from profound or prolonged syncope and sudden cessation of the heart's ac- tion, as upon quickly assuming or retaining the erect posture in states of exhaustion; (e) or lastly, from asphyxy, as pointed out in that article. Death may also occur much more slowly in acute mala- dies, owing to the gradual sinking and abolition of the vital manifestations; giving rise to the collapsed countenance, the frequent, weak, and unequal pulse and respiration; the loss of animal heat, and cold clammy perspirations, the resolution of the sphincters, and insensibility, the cadaverous smell, &c. observed some hours previously to, and usher- ing in, dissolution. In some chronic maladies, death often occurs suddenly, as in organic diseases of the heart, large blood-vessels and lungs, owing to effusion into the pericardium, interruption of the heart's contractions, to rupture of its cavities or valves, to bursting of aneurisms or profuse haemorrhages, to suffocation from effusion into the bronchi, or into the pleural cavities, &c. More frequently, however, death takes place slowly in this class of maladies; and is chiefly owing to the exhaustion of the vital energies, or to the disorgan- isation of some important part, and the interruption of a vital function, disordering and ultimately obstructing others; as when fluid is slowly effused in any of the large cavities. 162. VIII. Of the Relations, Successions, and Complications of Disease. — A. The relations of disease are not easily explained in many instances; in others, however, they are more ob- vious. It cannot be shown wherefore a state of erethism, or inflammatory irritation of the diges- tive mucous surface, should frequently co-exist with acute or chronic eruptions on the skin other- wise than by supposing that the state of the circu- lating fluid is such as to excite or irritate the vas- cular reticulations of both the skin and villous membrane; and, although this fluid may be in excessive quantity in the majority of such cases, yet quantity merely will not account for the phe- nomena, without calling into aid an alteration of quality; which, while it excites the digestive mu- cous surface, also inflames the cutaneous vessels, during the depurating process they exert upon the blood. But the state of this fluid will not explain all the relations of complicated morbid actions. The reciprocative influence of the or- ganic nervous and cerebro-spinal systems, and of the former and the vascular systems, must be considered as the earliest and chief sources of morbid associations. When the dependence of vascular action and of the secreting and excreting functions on the organic nerves,—of the conditions of the circulating fluid on the states of these func- tions,— and of the cerebro-spinal manifestations on both the organic nervous and vascular systems — on the strictly organic actions, — is duly con- sidered, the relation and succession of several morbid conditions will appear as necessary results of this union. When we perceive the processes of digestion, secretion, and defecation imperfectly performed— processes essentially dependent upon the organic nervous influence — should we be surprised to observe further disorder supervene ? and are we not rather to expect morbid phenom- ena to present themselves, referrible to the vas- cular system, to the circulating fluid, to the nutri- tive functions, and to the purely animal manifes- tations? When important eliminating processes are either impeded or increased to such a degree 52 598 DISEASE — its Relations, Successions, and Complications. as to constitute disorder, ought not other states of disease to be looked for ? When the urinary secretion is interrupted, excrementitious vascular plethora, followed by a morbid increase of the exhalations, dropsy, congestion or effusion on the brain, convulsions, coma, &c. will necessarily follow. When this excretion is morbidly increas- ed, the other secretions will be diminished, and assimilation and nutrition impeded. When the menstrual discharge is delayed or suppressed from torpor of the generative organs, an important depurating function is not performed, the co-exist- ent debility of all the organic actions is thereby increased, the cerebro-spinal functions are weak- ened; ultimately assimilation and nutrition are reduced to the lowest grade, and anaemia and marasmus supervene. But when this discharge is copious and frequent, owing to increased ac- tion or excitement of these organs, the blood is purged of its impurities, all the organic func- tions assume a proportionate activity, and the cerebro-spinal system evinces augmented suscep- tibility and excitability: sanguifaction and fre- quently nutrition proceed rapidly; and vascular plethora, with a tendency to local determinations, to inflammations, to hysteria, to convulsions, &c, is the consequence, particularly upon any inter- ruption of the discharge. 164. B. Also, when morbidly increased secre- tions have become habitual, other and more im- portant diseases may succeed any interruption they experience. An habitual diarrhcea, when sup- pressed, may be followed by peritonitis or ascites; an old bronchorrhoea, or chronic bronchitis, may, when arrested, be succeeded by hydrothorax; leucorrhcea, or menorrhagia, if injudiciously treated, may pass into inflammation of the womb, or of the peritoneum, and even into ascites. In these the succession of morbid actions admit of ready explanations; for these morbid secretions or discharges being generally the result of local determination and plethora, their interruption or suppression merely changes their direction from a surface, whence they were evacuated, and where they, consequently, were comparatively innocuous, either to the substance or to the sur- face of the organ or part affected, where their retention and accumulation occasion dangerous or fatal effects. 165. C. Whilst the mutual dependence—the reciprocative influence — of the different systems and functions of the frame, explains the relations and successions of diseases, it also accounts for their complications, and for the comparative in- frequency in practice of those simple or specific forms or states of morbid action described by nosologists. Indeed, when we reflect on the in- timate manner in which the various parts of our frame are anatomically related and functionally dependent, we should rather be surprised to find disease so simple as it often is, and be prepared to observe not only associated lesions of structure and disorders of function, but also the one va- riously complicated with the other. There are numerous circumstances which favour the com- plication of disease. Amongst these the follow- ing are the most important:—1st. Constitution and diathesis, — as the scrofulous, the rheumatic, the gouty, the plethoric, and the debilitated;— 2d. The nature of the predisposing and exciting causes, viz. those which act upon the organis- ation generally, as impure air, unwholesome food, &c.; — 3d. The state of the secretions and excre- tions, particularly the vitiation or interruption of them;— 4th. Vascular plethora, anaemia, and a morbid state of the blood; — 5th. The disposition of membranous or continuous parts to experience an extension of morbid action, particularly when vital resistance is weak, and the excretions un- natural or interrupted;— 6th. The influence of irritation of a part upon remote organs, through the medium of either the organic or cerebro-spi- nal nervous systems;—and, 7th. Injudicious treat- ment. It would be inconsistent with my limits, were it possible, even to enumerate the compli- cations which result from these and other causes; but there are certain illustrations required to show the truly practical importance of this branch of pathology. 166. (a) Tubercular productions in the vis- cera, or in the membranes, often co-exist with disease of the absorbent vessels and glands. Rheu- matism and gout not merely modify the character of other diseases, but may seize on a number of parts successively, and even on several simultan- eously, whilst they are very often associated with a torpid state of the liver and bowels, and disor- der of the stomach and urinary organs. A ple- thoric state of the vascular system, whether abso- lute or relative, associates congestions of internal viscera with various disorders of secretion and excretion; with affections of the nervous system, and of the female generative organs, and some- times with eruptions on the skin. Debility dis- poses to the extension of inflammatory action to continuous or contiguous parts, and associates disorders of the digestive and assimilating viscera with those of the nervous system and sexual or- gans ; and thus examples of the succession and com plication of disease from diathesis and constitution (§ 165, 1st.) are constantly appearing in practice. 167. (b) Extremes of temperature, and hu- midity, and impure air ofted seriously affect more than one organ. A warm and impure air frequently produces, either successively or simul- taneously, not only functional but also structural disease of the liver, spleen, and bowels, as well as fevers in which these viscera and the stomach are principally affected. Unwholesome food con- taminates the chyle, the circulating and secreted fluids, and ultimately occasions co-existent disease of several viscera, — the complication of causa- tion (§ 165, 2d.). 168. (c) A vitiated, copious, or interrupted state of one or more secretions not only affects the organs which produce them, and the viscera to whose functions they are either directly or indi- rectly subservient, but also vicariously influences other secretions, and changes their quantity or quality. A copious flow of acrid bile may com- plicate disease of the liver with inflammation of the mucous surface of both the stomach and the intestines, particularly of the latter; and func- tional disorders, or inflammations, or structural change of the kidneys, may so alter the conditions of the urine and blood as to associate with them either renal and vesical calculi, or inflammation and structural disease of the urinary bladder, or dropsy of one or more of the shut cavities, and of the cellular tissue. Also, interrupted discharge of the secretions, particularly of those that are excrementitious, from disease of their outlets, not DISEASE —Metastasis of. 599 infrequently occasions consecutive changes in the organs which elaborate or retain them. Obstruc- tions to the due evacuations of the urine, from ob- stacles existing either in the urethra, or about the neck of the bladder, or in the ureters, superinduce alterations of the kidneys, or of the bladder itself; and disease of the biliary ducts commonly associ- ates with it lesions of both the gall-bladder and liver, and of the digestive canal; furnishing exam- ples of superinduced complications (§ 165, 3d.). 169. (d) Changes in the quantity and quality of the circulating fluid, especially when carried far from the healthy state, although usually the consequences of disorder of one or more of the secreting and assimilating viscera, yet become the causes of co-existent disease of several organs, and structures, modifying their interstitial secre- tions, their nutrition, and their vital cohesion and manifestations; the whole organisation generally presenting more or less of change. These com- plicated effects may assume varied forms, and implicate particular organs in a more remarkable manner than the others, according as either ple- thora or anaemia may be associated with the accu- mulation of excrementitious matters in the blood, or as the quantity and nature of these matters may vary — thereby causing diversified humoral complications (§ 165, 4th.). 170. (e) — a. When we advert to the circum- stance of disease essentially the same having differ- ent symptoms, and producing varied effects, mere- ly in consequence of a slight difference in its seat, one reason for the frequency of what should be called rather the extension or succession of disease, than its complication, will be apparent. Thus, when inflammation of the fauces extends down the "trachea and bronchi, there may be either a suc- cession of disease, if the inflammation disappears from the former seat as it extends to the latter; or a complication, if it exist at the same time in all; and yet the nature of the morbid action is essentially the same, as long as the vital energies remain unaltered. When inflammation extends along the digestive mucous surface, or to distinct parts of it only, a similar succession or compli- cation, but without difference of the nature of the disease, also obtains. These are instances of the succession or complication of continuity.—p. But disease may extend from one tissue to another, instead of being thus limited to the same, as in the above instances; —it may originate in a mem- branous surface, and involve the substance or parenchyma of an organ, and ultimately even its opposite and differently organised surface, and either disappear from the former upon affecting the latter, or implicate them all simultaneously, thereby giving rise to a succession or compli- cation of morbid actions, without altering their characters, although materially changing their symptoms. Thus, bronchitis may pass into pneu- monia, and this latter into pleuritis, or they may all co-exist; and inflammation of a part of the digestive mucous surface may be extended to the cellular tissue connecting the coats of the aliment- ary tube, and thence to the peritoneum; and so on in respect of other organs, which, equally with these, not infrequently furnish examples of the suc- cession or complication of contiguity (§ 165,5th.). 171. (/) Irritation and other disorders of an organ or part not infrequently associate with them a morbid condition of remote as well as adjoining | parts. Worms in the intestinal canal often induce either febrile or convulsive affections. Congestion, inflammatory irritation, erethism, or merely func- tional excitement of the female organs, may occa- sion epilepsy, irregular or anomalous forms of convulsions, hysteria, altered sensibility of the nerves—referred by some writers to irritation of the spinal cord—vitiated appetite, and disordered manifestations of mind. Injury of a tendon or nerve may produce tetanus; and the accumu- lation of faecal matters in the large bowels may excite, and be complicated with, various disorders of the stomach, inflammation and ulceration of the fauces and pharynx, febrile disturbance, haem- orrhoids, numerous nervous ailments, and disor- ders of the uterus. These may be termed the sym- pathetic associations or complications of disease. 171. (g-) That injudicious treatment often com- plicates disease, may not be so readily admitted as the circumstances now adverted to. But I can state, as the result of observation, that lowering measures carried too far will occasionally favour the extension of disordered action and structural change, either by continuity or contiguity (§ 170.), or by promoting the function of absorption, and the passage of morbid matters into the blood (§ 169.); and that stimulating remedies used too freely will, either by their operation on secreting organs and surfaces, or by irritating the parts to which they are applied, sometimes superinduce inflammatory action in addition to the disease which they were intended to remove. Thus, arsenic exhibited too freely, in order to cure agues, has produced in- flammation of the internal surface of the heart and arteries; and bark or quinine, given freely before morbid secretions and faecal matters have been carried off by purgatives, has superinduced hepa- titis or dysentery, or both, upon the intermittent disease for which it was prescribed. Stimulants and tonics taken in some forms of dyspepsy, as complicated functional or structural disease of the stomach, liver, and bowels,; and astringents im- prudently employed, have excited inflammation in the organ whence the discharge, for which they were exhibited, proceeded, as well as disease in some related organ. 172. IX. Of the Metastasis of Disease. — Metastasis (utraaraaig, a change, migration, from utdiOTtjui, I change, or transfer) of disease has been often improperly confounded with the terms Metaptosis, Epigencsis, Diadoxis, and-Me- taschematismus, which have had different meanings attached to them. Metaptosis has usually been used to mean a change in the nature or state of a disease, without a change in its seat;—Epigcnesis, the superinduction of another, upon an antecedent, disease; the anterior affection not being amelior- ated by the occurrence;—Diadoxis, the succession of a less, to a more, important malady;—Metas- chematismus, the transformation of disease simply; —and Metastasis, the displacement or disappear- ance of disease from one part of the frame, and its seizure of another of more vital importance. It will be perceived, that the phenomena which these terms have been employed to express, have been already noticed, excepting those which fall under the last. When rheumatism or gout disappears from a joint and attacks the head, heart, or stomach ; or when erysipelas, or any febrile or chronic erup- tion, forsakes the surface and is followed by angi ua, or pneumonia, or internal abscess, or inflam 600 DISEASE —Metastasis of. mation of the alimentary canal, or peritonitis; there is a metastasis, or change of the seat, of the disease. 173.-4. There are certain topics connected with this subject, which have been much discussed, viz. Whether the disappearance of disease from its original seat is the consequence, or the cause, of its seizure of another part; and through what channel does the transfer take place. The abettors of the humoral pathology explained the occurrence of metastasis, by considering that a transfer of the materies morbi, or morbid matter, takes place from one part to another, through the vascular system; and that the consecutive disease is gene- rally the consequence of the disappearance of the antecedent. The supporters of solidism, whether with reference to nervous influence or to the doctrine of excitability, supposed that disorder manifests itself in the new seat owing to its sup- pression in the old, — the cerebro-spinal nervous system being the medium of displacement; whilst they admitted — particularly the disciples of Brown — that its irruption in the former fre- quently subdues it in the latter, owing to the ex- citability being more intensely acted upon in the one than in the other. A greater desire, however, has been displayed by either class of theorists, to conform facts to their views, than to investigate the matter in a legitimate manner. In order to draw accurate inferences, it is necessary to inter- rogate Nature herself, by an intimate observation of the phenomena to which the term metastatic has been applied ; and, when the practical im- portance of this subject is considered, the results will repay the investigation. A few facts which have fallen under my observation will serve to elu- cidate the subject.—1. A medical friend had gout in the lower extremities, for which he took a large dose of colchicum before the morbid secretions had been evacuated. He almost instantly had a violent attack of the disease in the stomach, with simul- taneous disappearance of it from the original seat. The free use of stimuli caused it to relinquish the stomach, and to reappear in the extremities. In this case, the transfer from one place to the other was instantaneous ; the medium being evidently the nervous system.—2. Another patient had, upon suppression of gout from the lower extremities, an attack of simple apoplexy, for which he was bled and purged. When I saw him, he was still com- atose. The head, however, was cool. I directed mustard cataplasms to the feet, and camphor and ammonia internally. The gout suddenly reap- peared in the feet, and at the very same instant he awakened as if from a profound sleep, evincing not the least cerebral disturbance, organic or func- tional.—3. A middle-aged and not robust man had most severe rheumatism in the thighs and legs, for which he took a large dose of croton oil, which produced hypocatharsis, and the complete ces- sation of the pains of the limbs, followed by the most distressing agony referrible to the heart, with palpitations, &c. He was actively treated, but he died in a day or two. With the exception of a somewhat increased vascularity of the substance of the heart, no disease could be detected in any part of the body.—4. A female, about 30, san- guine and plethoric, had rheumatism of the lower extremities, which she attempted to remove by a quack embrocation. The disorder disappeared from the extremities, but she was Instantly seized by most acute pains and tenderness in the re- gion of the uterus and ovaria, the latter being greatly enlarged, so as to form small tumours. Similar cases to the above have been observed by me, and show that rheumatic and gouty diseases, when suppressed in one part, or suddenly subdued by lowering remedies or evacuations, will often be manifested in some vital organ, and be remov- ed from it, in such away as can be explained only by nervous agency: and, when the conformation of the parts consecutively affected are considered, and the proneness of the disease thus superinduced to assume an inflammatory and congestive state, retaining at the same time the gouty or rheumatic character, is taken into account, it is reasonable to suppose that the organic nerves are the chief channel of transfer, and seat of the affection; their intimate anatomical connection with the blood-vessels explaining the morbid state of vas- cular action with which the transferred disease is so frequently accompanied. 174. B. But there are metastases of a some- what different kind from the above ; but which, equally with these, present morbidly excited action: the difference consisting chiefly in the extreme de- gree in which sensibility is altered in those already noticed. In the exanthemata, and even in the course of several chronic eruptions, the cutaneous affection suddenly disappears, and dangerous disease is developed in an internal organ. In some cases, the superinduced malady is merely the localisation or determination of the morbid action to a single organ, the external affection disappearing in consequence — a result not infre- quently of depression of the powers of life, or of irritants acting upon the part thus secondarily diseased, or of both causes conjoined. In other instances, particularly in chronic eruptions and discharges, the internal or consecutive malady is the consequence of the suppression of the external disorder. In order to form an opinion relative to the nature of metastasis in exanthematous diseases, it is necessary to attend to the following circum- stances :— 1st. That they are frequently caused by the neglect of sufficient evacuations early in the disease, by a cachectic habit of body and con- stitutional vice, by breathing a foul air, and by injudicious regimen ; — 2d. That whatever sud- denly lowers the nervous energies, or weakens vital resistance to hurtful agents, or perturbates the frame, will often cause a metastasis of the disease; —3d. That the metastasis may be either complete, the external eruption disappearing entirely ; or incomplete, the eruption still partially remaining. In these diseases, the morbidly excited vascular action of the skin evacuates a peculiar matter, which is capable of propagating the disease, and which is either carried off chiefly in the insensible perspiration, as in measles and scarlatina, or in the more consistent matter of the eruption, or in both, as in small-pox. When, therefore, the morbid vascular action and its attendant evacu- ation are either prevented from appearing in, or suppressed from, the cutaneous surface, it may be reasonably inferred that they will be determined to some internal viscus, giving rise to inflammation of, and serous effusion from, mucous or serous | surfaces; and congestions, infiltrations, inflam- i mation or hepatisation of parenchymatous organs. | Thus, in scarlatina, measles, small-pox, erysipelas, ! &c. the suppression of the eruption not infre- j quently produces one or more of the above effects, I and constitutes the chief diseased appearances in fatal cases. DISEASE — Circumstances modifying the Form, etc. of. 601 175. C. There is another form of metastasis, that consists chiefly of morbid secretion; and although vascular action is concerned in producing the matter found in the secondary seat of disease, still the transfer from the original seat evidently takes place through the channel of the circulation. We not infrequently observe purulent or ichorous matter, which has been formed in one part, re- moved from thence, and infiltrated, or secreted and accumulated, in another part ; occasioning consecutive abscesses (see Abscess), or some other structural change, in a parenchymatous organ, or puriform effusion into natural cavities. In these cases, the passage into, and presence of morbid matter in, the blood, excite increased vascular action in some part by means of which it is either evacuated from the system, if the morbidly excited part be an emunctory; or infil- trated and collected, if it be a parenchymatous organ; or effused and retained, if it be a serous or synovial cavity. Thus, collections of puriform matters have been found in the liver, in the joints, in the lungs, in the brain, &c. after small- pox, erysipelas, fevers, inflammations of veins, or of remote or external parts, and after fractures; and often without any antecedent disease of the viscera thus consecutively disorganised, or disorder referrible to them, proportionate to the extent of disorganisation observed on dissection of fatal cases. 176. D. From the foregoing I conclude, 1st, That metastases may be divided into—(a) those manifesting fully expressed disordered action, in which the sensibility is more or less excited; and (b) those consisting of latent disorganisation, and produced chiefly through the medium of the circu- lating fluid: or into—(u) those which affect the substance of an organ; and (p) those which take place to an excreting surface or viscus — as the skin, the intestinal mucous surface, the kidneys, and the salivary glands — and which frequently terminate favourably by evacuation from the cir- culation of noxious matters that were the chief cause of the metastasis. — 2d. That they are brought about — (a) by means of the organic nervous system, as in gout and rheumatism; — (b) by the influence of this system of nerves upon the blood-vessels and capillaries, determining to various surfaces or structures a preponderating degree of morbid action and its results, according to the operation of numerous intrinsic and ex- trinsic causes, as in exanthematous metastases;— (c) by the absorption of hurtful matters into the circulating current, where they excite, internally as respects the capillaries, the increased or morbid action of some secreting surface or emunctory, or occasion the disorganisation of some predisposed parenchymatous organ. 177. X. The Circumstances modifying the Form, Complications, Duration, and Terminations of Disease, are as numerous as the causes, — predisposing, exciting, and deter- mining,—in which it originates. The constitution and diathesis of the patient; a cachectic or vitiated habit of body ; the continued operation, during the course of the disease, of the causes which in- duced it ; the depressing passions ; impure or stagnant air; all sudden mental and physical per- turbations ; extremes of temperature ; injudicious treatment and regimen ; the use of medicines which either suddenly or intensely excite, or de- press, the vital or nervous energies, and weaken the restorative powers ; neglect of evacuations, 51 I and of the state of the secretions and excretions; I the nimia diligentia of the practitioner, or im- proper interference with the salutary processes of nature, and with critical evacuations and changes, the too early recurrence to a full or stimulating diet, or exposure during convalescence to any of the causes specified above; will not only modify the states and duration of disease, but also occa- sion the succession of one disease into another, render morbid action more or less complicated, transfer it from one structure or organ to another, and occasion relapses of greater or less severity. 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Paris, 1767. — E. Sandifort, Ob- servat. Anatomico-Paihologicae, 4 vols. 4to. c. fie. Lugd. Bat. 1777—1780.—C. F. Ludwigii, Primae Lineae Anat. Pa- thol. Lips. 1785, 8vo.—Vicqd'Azyr, Anat. Pathologique, in Encyclopedic Melhodique. Paris, 1789.—M. Baillie, The Morbid Anatomy of the most important Parts of Ihe Human Body, 8vo. Lond. best edit, edited by J. Wardrop, 2 vols. 8vo. Lond. 18i7.—G. C. Conradi, Handbuch der Patholo- gischen Anatomie, 8vo. Hannov. 1799.—A. R. Vetter, Aphorismen Aus der Pathol. Anat. Wien. 18U3.—Prost, Medecine eclairee par l'Observation et l'Ouverture del Corps, 2 t. 8vo. Paris, 1804.—Zeune, De Vitiis quibus Corp. Anim. Obnoxium e-t Organicis. Viteb. 1804.—portal, Ana- tomie Medicale, kc. 5 tomes. Paris, 1805.—F. G. Voigtel, Handbuch der Pathol. Anat. 3 bdc. 8vo. Halle, 1804.—^. F. Meckel, Handbuch der Path. Anat. 2 bde. 8vo. Leips, 1812—1818.— J. Farre, Pathological Researches in Me- dicine and Surgery, 8vo. Lond. 1814.— J. W.Francis, Cases of Morbid Anatomy, 4to. N. Y. 1825. —J. Cru- veilhier, Essai sur I'Anat. Pathol, en General, et sur lei Transformations et Productions Organiques en particu- lier, 2 t. 3vo. Paris, 1826. ; et Anat. Pathol, du Corps Hum., ou Descriptions avec Figures Lithog. de diverse! Alteration* Morb. kc. fol. liv. i.—xv. Paris, 1828—1833. —A. W. Otto, Seltene Beobacht. zur Anat. Physiol, und Pathologie Gehrig, 4to. Breslau, 1816—1824.; et Ver- zeichne ss der Anat. Praparaten Sammlung d s Kbnigl. Anatomie-Instituts zu Breslau, 8vo. Bresl. 1826.—J. F. Meckel, Tabulae Anatomico Pathologicae, kc. fol. fasc. i.— iv. Lips. 1817—1826.—J. B. Palletta, Exercitat. Patho- logicae c. Tab. .En. 4to. Mediol. 182 1—1286.—Consbruch, Taschenhuch der Path. Anat. fur Praktische u. Wundarzte, 8vo. Leips. 182). — P. J. Wassermann, De Mutat Patho- logicis primitivarum in Organismo Humano formationum, 8vo. Padua, 1820.—Tacheron, Rechercl.es An4. Pathol. sur la Med. Pratique, etc. 3 t. 8vo. Paris, 1823.—Poilroux, Rech. sur les Mai. Chroniques et sur les Affect. Organiquei et lei Mai. Hereditaires, 8vo. Paris, 1823. — X. Bichat, Anat. Pathologique, par Boisseaux, 8vo. Paris, 1825.— Merat, in Diet, des Sciences Medicates, vol. xxvii. p. 485., vol. xxxviii. p. 138., et vol. It. p. 210.—Laennec, Sur I'Anat. Pathologique, in Journ. de Med. par Corvisart, Leroux, kc. t. ix. p. 360. ; et Diet, des Scien. Med. vol. ii. P. 46.—Le Blanc et Trousseau, in Archives Generales de Med. t. xvi. p. 522., t. xvii. p. 165., t. xviii. p. 336.—Deze- imeris, in Ibid. t. xx. p. 157. 358. t. xxi. p. 5. 161. 325. et 481.—Ribes, De I'Anat. Patholog. consideree dans ses Vrais Rapports avec la Science des Maladies, t. i. 8vo. Paris, 1828. G. Andral, Precis d'Anatomie Pathologique, 3 tomes, 8vo. Paris, 1829.—^. F. Lobstein, Traite d'Anatomie Patholo- gique, t. i. Piris, 1829.—J. Hope, Principles and Illus- trations of Morbid Anatomy, &c. 8vo. part vi. 1832—1833. —R. Carswell, Illu-trations of the Elementary Forms of Disease, fasc. i. et ii. 4to. Lond. 1833. iv. Periodicity of Disease.—Stahl, De Affect. Pe- riodicis. Halae, 1702.— Valentini, De Periodis Morbo- rum. Franc. 17J1. — Buchner, De Primis Viis Morb Period. Sede frequentissima. Halae, 1768.—Ploucquet, De Morb. Periodicis. Tub. 1783. —Stoetzer, De Morb. Recurrentibus, Recidivis et Periodicis. Jenae, 1789.— J. Testa, Bemerk. iiber die Periodischen Veranderungen u. Erscheinungen, kc. ; et in Journ. de Med. t. xc. p. 262. — Franck, De Periodicarum Affectionum Ordinandi DROPSY — Pathology of. gQ3 Familiu. Pav. 1791. — Ballhorn, Diss. Quorundarum Phaenoinenorum Period. Causae probabiles. Goet. 1792.— Rhetorides, De Morbis Periodis, kc. Erlang. 1809. v. Successions, Complications, and Metastasis OF Disease.—Baglivi, De Febra Motrice et Morbosa, &.c. Opp. p. 367. — Stahl, De Morbis Consequentibus. Halae, 1710. ; et De Metaschematismis Morborum. Hal. 1707. ; et de Morb. Complicatione. Halae, 1715.—F. Hoffmann, De Morb. Transmutations. Halae, 1716 ; Opp. Supp. ii. 1. — Voter, De Morb. Complicate et Intricatis. Witeb. 1728.— Zannutti, De Morb. Complicatis. Wien. 1719__ Eschenbach, Do Morborum in Morbis Pluralitate. Rost. 1744. — Hebenstreit, De Metaschemati mo Morb. Lips. 1747.— Segner, De Mutationibus Morb. Goet. 1747.— Boehmer, De Morb. Crisi Metaslatica. Hala;, 1763.— Schroeder, De Febrilibus Metastasibus. Go2t. 1764. — Schlegel, De Metastasi in Morbis. Jenae, 1771.—Leiden- frost, De Morb. Complicatis rite dijudicandis. Duisb. 1769. ; et in Opusc. vol. iv. n. 2. — Roettboel, De Suc- cessione Morb. Hafn. 1776. — Consbruch, De Crisi et Metastasi. Stuttg. 1781.—Lorry, De Praecipuorum Morb. Mutationibus, et Conversiouibus. Paris, 1784. — Soual, De Morb. Metaschematismis. Marb. 1794.—Wolfart, De Genii Morb. Mutalione Hominum Vitae Ralioni tribuenda. Marb. 1797. — St. Colombe, Essai sur les Metastases. Montp. 1800. — Thomann, Annalen ad 1800. — J. D. Brandis, Versuch iiber die Metastascn, 8vo. Hanno7. 1798. —Hartog, De Modis et Causis quibus fiunt in Corp. Hum. Metastases. Ultraj. 1802. — Kieser, in Hufeland's Journ. der Prak. Heilk. Jan. 1812. — Ferriar, Medical Histories, vol. ii. n. i.—Erdmann, De Metastasibus. Viteb. 1810.— Reydellet, art. Metastase, in Diet, des Scien. M£dicales, t. xxxiii. p. 17.—Scoutetten, in Journ. Univers. des Scien. Med. t. xxx. p. 129.—Charmeil, in Journ. Univers. &c. t. xxiii. p. 309., et. t. xxv. p. 75. DROPSY. —Syn. "YSomxp, Th. (TWo, water, and Si-d', aspect, appearance). Hydrops, Lat. Hydropisie, Fr. Die Wassersucht, Die Hy- dropsie, Germ. Idropisia, Ital. Classif.—3. Class, Chaectic Diseases; 2. Order, Intumescences (Cullen). 6. Class, Diseases of the Excremental Function; 2. Order, Affecting Internal Surfaces (Good). IV. Class; I., II., and III. Orders (Author). 1. Nosol. Defin. The accumulation of wate- ry fluid in the natural cavities, or in the cellular areola, or in both, causing distension, impeded functions of the affected and adjoining parts, fre- quently with fluctuation, softness, fyc. Pathol. Df.fin. A collection of fluid arising either from increased exhalation or from dimin- ished absorption, each of which conditions depend upon antecedent states of disease. 2. After having taken a general view of the nature and treatment of dropsical effusion — of Dropsy in its generic acceptation, — I shall pro- ceed to consider its specific forms. By thus view- ing, in a connected manner, the various species of dropsy, which have been improperly separated the one from the other, much unnecessary repetition will be avoided, and several advantages obtained. 3.1. Pathology of Dropsy.—i. Brief His- torical View of Opinions.—Different views of dropsical diseases may be found in several parts of the writings ascribed to Hippocrates. There can be no doubt, however, of the connection be- tween them and a state of active vascular disorder, as well as of obstructions of the liver and spleen, having been known to him. Erasistratus is said to have referred these maladies chiefly to engorgements of the liver; and Asclepiades to have viewed them as being either acute or chronic. Aretjeus gave merely a lively description of the history of dropsies: but Galen, in the uncon- nected observations on these maladies scattered through his writing-s, stated some just views of their nature. He pointed out the seat of the ascitic effusion ; contended, in opposition to Erasistratus, that dropsies often depend upon other causes, and upon disease of other viscera, beside hepatic obstruction ; and that they fre- quently proceed from a morbid state of the blood. Cjelius Aurelianus assigned, as their causes, lesions not only of the liver, but of the spleen, of the womb, and of the large and small intestines. Aktius made some reference to a cachectic habit of body in relation to them; and Alexander of Tralles noticed, but in a superficial manner, their connection with diseases of the lungs, and with antecedent fevers and inflammations. 4. Amongst the Arabian writers, little respecting dropsy beyond what is contained in the works of their predecessors is to be found. Avicenna, however, attributed it to the liver and to the kid- neys; and stated that the latter, owing to the cold- ness or warmth of their temparature, or to obstruc- tion or induration of their structure, fail to attract or separate the watery fluids. Mesue gave a similar view to the foregoing, and both agreed in stating that the liver does not concoct pure, but a watery and phlegmatic, blood. When we reflect that the lights of modern science have shown that the liver is both indirectly and directly concerned in sanguifaction; that the crasis and vital constitu- tion of the blood is really affected in many states of dropsy, and that the kidneys are often very de- monstratively diseased, and in a way that may be expressed in general terms nearly similar to those used by Avicenna, we must conclude, that some of the pathological opinions of the ancients are not so despicable as many of the moderns sup- pose; and that, even in recent, as well as in bygone, times, there have been more absurd theories than sound views of morbid actions, and a greater disposition to generalise from a few im- perfectly ascertained states of disease, than to take into account numerous concurrent circum- stances and morbid associations. 5. Since the revival of learning, but little was added to the knowledge of dropsies, until the writ- ings of Willis appeared. This very eminent physician first called in the state of the vessels to the explanation of these diseases; and argued that, whilst the vascular extremities are either too re- laxed or too constricted, causing thereby an increased effusion and diminished absorption respectively, the blood itself is often altered, and its circulation impeded by scirrhous tumours, tu- bercles, and obstructions in any of the abdominal viscera. Ettmuller and Lister adopted the views of Willis. The experiments of tying the veins, first performed by Lower, confirmed the opinion promulgated but not carried its due length by Willis, that interruption of the venous circulation is a chief cause of dropsical effusions. F. Hoffmann repeated the experiments of Low- er, and,as well as Boerhaavf. and Van Swie- ten, admitted the importance of venous obstruc- tion in the pathology ofdropsies. Mo rgagni says, " Qnacunque causa diutius potest sanguinis aut lymph® cursum morari, aut humoris quo cavae corporis madent, aut secretionem augere, aut exit- um deinde imminuere morbo huic potest originem praebere." Ludwig first directed attention to an atonic state of the vessels as a principal source of those maladies, and his contemporary Milman assigned as their chief causes a laxity of the fibres, exhausted power arising from copious evacuations, and acute diseases passed into the chronic state, 604 DROPSY — Causes or. and an obstacle to the return of the blood through the veins. The views of Haller were nearly thoseof LoDWiGand.MiLMAN;but he considered not only that the mechanical obstruction, but also that that grade of debility of the veins, which would retard their circulation, would occasion dropsies. The opinions of D. Monro, and Cul- len coincided with the foregoing; the former considering, and indeed proving by experiment, that the notion entertained at the time he wrote, as to rupture of the lymphatics being a cause of the effusion, was not well founded. 6. When lymphatic absorption became gene- rally insisted upon, owing to the writings of Huntfr, Hewson, and others, an additional cause of these maladies was acknowledged, and, as might have been expected, the part assigned to these vessels was greater than they perform. Vogel applied the doctrine of atony to them; and most of his contemporaries entertained a similar view. Soemmerring, Wedel, Assilini, and Mascagni, nearly altogether deprived the veins of their share in the production of aqueous effu- sion, and assigned its source almost entirely to the lymphatics. These writers, with many of their predecessors, still conceived that the rupture of these latter vessels sometimes caused it, and adduced cases in which this lesion was detected on dissection. Mascagni considered that, besides other alterations, the absorbents are either ob- structed in their glands, or dilated to such an extent as to prevent their valves from opposing the reflux of the fluids absorbed by them. The un- tenable hypothesis of a retrograde action of these vessels was advanced by Mezler and Darwin, but found no support. 7. The division of dropsies into active and pas- sive, or acute and chronic, may be traced to. Riviere, or Riverius, who denominated therrf hot and cold. Bof.rhaave, Backer, Tissot, Stoll, and later writers, have given greater pre- cision to this division, by denominating the former plethoric, active, sthenic, and inflammatory, ac- cording to the state of the circulation and of vital action. It was, however, chiefly Tissot, Stoll, and J. P. Frank, who drew attention to active, plethoric, or acute dropsy; andGRAPENGiF.ssER, the pupil of Frank, Blackall, Fauchif.r, Poilroux, Brf.schet, Abercrombie, and Ayre, have further illustrated this doctrine. Gra- pf.ngiessf.r, with much justice, observes, " Om- nis, enim, inflammatio modica si organon secer- nensoccupat,functionemejusauget." Geromini, a recent Italian writer, carried the inflammatory origin of dropsy as far as a medical sectarian might have been expected to have done, and discarded venous obstruction from any share in the produc- tion of this lesion. The facts, however, which have been adduced by Dr. D. Davis, M. Bouil- laud, M. Velpeau, and Dr. R. Lee, demon- strate the important part obstruction of the veins performs in the causation of at least partial drop- sies; and the interesting researches of Dr. Bright, followed up by Dr. Christison and Dr. I. Gre- gory, disclose the great share the kidneys have in occasioning this class of diseases. As to the existing state of our knowledge of their pathology, fuller details will appear in the sequel. 8. ii. Of the Causes of Dropsies.—It is evident that the chief causes of these diseases are the pre-existing lesions which will be hereafter described. But there are others, more remote in their operation, which deserve to be succinctly noticed. — A. Remote causes. — a. The predis- posing causes are chiefly a cold and moist climate, or a warm and moist temperature when conjoined with an impure air ; the lymphatic, phlegmatic, and bilious temperaments; a soft, re- laxed, and plethoric habit of body; the scrofu- lous diathesis (Heister); the syphilitic taint (Piderit and Hufeland); and advanced age. The infrequency of these maladies in warm and dry climates, as Egypt, Syria, Arabia, and Nubia, »has been remarked by several writers.— 6. The exciting causes are, — 1st, External, or physical agents, which occasion chiefly the more idiopathic and active forms of dropsy; and, 2d, Antecedent diseases.—u. Of the former, the most influential is cold conjoined with moisture, par- ticularly if acting upon a person in a state of perspiration. The influence of a humid atmos- phere may be imputed to the circumstance of its impeding the pulmonary and cutaneous trans- pirations, and occasioning the accumulation in the vascular system of the watery parts of the blood, or a recrementitious plethora, if the kidneys perform not a proportionately increased function; and this effect is promoted if cold be superadded. When a moist air is loaded with miasmata, the injurious effects are still further heightened, as internal congestions and obstructions of the liver and spleen are thereby produced; humidity and cold frequently giving rise to acute, and warm moisture with malaria to passive, dropsies, or those depending chiefly on visceral obstruction. The operation of humidity in causing these diseases was explained by Erastus, Van Swieten, and De Hafn, on the supposition that a portion of the moisture was absorbed from the air into the circulation. Unwholesome food and a poor and watery diet, although justly considered as a cause by Bonet, FoTHERGiLL.and others, can act only by debilitating the frame, and inducing a state of general cachexy, or disease of some viscus terminating in effusion. Van Helmont and Pezold conceived that the use of pork is productive of dropsies; and I believe that there is some truth in the opinion. That this diet favours the generation of the scrofulous and gouty diathesis, is certainly a result of my observation. Drinking cold fluids, particularly when the body is perspiring and fatigued, not infrequently causes the active states of these diseases ; and all kinds of ingurgitation, especially drunkenness, are per- haps the most common agents, in as far as they seldom fail of producing those visceral lesions on which watery effusion so often depends. Violent fits of passion were considered by Lu- dolff and De Meza, indolence by Tissot, se- dentary occupations by Ramazzini, and gene- ral debility by Wainewright, Df. Haem, D. Monro, and Ludwig, as occasional sources of dropsies. The influence of anxiety and the de- pressing mental emotions, in favouring their oc- currence, if not in directly exciting them, cannot be doubted. Pregnancy, and abortions; severe injuries, succussions and concussions of the trunk (Bonet, Df. Haen, &c),difficult dentition, may also excite some one of these maladies. The com- plication of ascites with p?egnancy has been observed to every practitioner. The sudden sup- pression of cutaneous eruptions and accustomed DROPSY — Appearances on Dissection. 605 discharges is one of the most common causes of dropsical effusions,particularly when other concur- rent circumstances are present. Lentin ,Haute- sieck,Bacher,Rifdlin,Thilf.nius, Wil- lich, Schmidtmann, and Frank, insist much upon the repulsion of the acute exanthemata and erysipelas; and Gmelin, Hufeland, and Osi- an der, upon that of the itch, herpes, lepra, and porrigo. I have often seen acute hydrocephalus appear after the use of external remedies in the cure of porrigo, to the neglect of internal measures. Morgagni, Piso,Guyon,Fischer, Michae- lis, and others, instance the occurrence of acute dropsies after the suppression of gout and rheuma- tism; Cjelius Aurelianus,Rhodius,Fores- tus, and Sr hmoegf.r, after the disappearance of haemorrhoids; and Morgagni, Hoffmann, Ab Hef.r,Obf.rteuffer, Demiani, Bris- bane, Frank, and Fauchier, after the sup- pression of the menses and the lochia. The sud- den arrest of an habitual diarrhcea and of chronic dysentery has been observed by Hippocrates, Riedlin, Frize*, and Stoll, to produce effu- sion, particularly in the peritoneal cavity; and general dropsy has been observed by Bartholin, Lister, De Haen, Pomard, and Lentin, to result from suppression of urine. That aqueous effusion should follow excessive depletions and haemorrhages, has been doubted by some of those who consider it as a consequence of plethora or increased action: but Forestus, Blank a rd, Hoffmann, Haller, De Haen, D. Monro, Gordon, Helwig, and others, have met with such occurrences. 9. p. The diseases upon which dropsy most commonly supervenes, are chiefly fevers, and vis- ceral inflammations and obstructions. Quotidian and quartan intermittents, and bilious remittents, when purgatives have been neglected, or when bark and stimulants have been too freely exhibited, to the neglect of requisite evacuations, are often followed by dropsy. Thomann states, that he has seen it consequent upon sanguineous evacua- tions carried too far in these maladies. The occurrence of effusion as a termination of inflam- mations, particularly of serous membranes, and from diseases of the heart, lungs, liver, and spleen, has been generally admitted in modern times. The frequency and the characters of dropsy after scarlet fever have attracted the notice of most writers on these diseases, particularly of With- ering, Frank, Ploucquet, and Hufeland. Its occasional supervention during phthisis, bron- chitis, chronic catarrh, and hooping-cough, must have been familiar to every physician of expe- rience. An aqueous or aqueo-sanguineous effu- sion into the serous cavities was a common cir- cumstance in the scurvies which formerly proved so destructive to fleets and armies. The connec- tion of dropsies with chronic and obscure diseases of the kidneys, imperfectly noticed by Aetius, Avicenna, Mesuk, Lentin, and Tiling, and fully established by the researches of Dr. Bright, is of the utmost practical importance. The occa- sional dependence of these maladies upon lesions of the uterus and alterations of the organs already mentioned, as wejl as upon others, will be more particularly noticed hereafter. 10. iii. Appearances observed on Dis- section.— A. In the cavities and parts the seid of the effusion.—(a) The serous membranes 51* are frequently found thickened and opaque, some- times softened, and occasionally harder than natural. In many cases, evidence of antecedent inflammatory action, as coagulable lymph, and cellular bands, or the remains of old adhesions, exists in the pleurae or peritoneum. Bonet ob- served the latter membrane inflamed and covered by a mucus-like matter; De Haen and Barron, granulated or tuberculated; Tacheron and Ay re, thickened, opaque, and white; and Sto- erck and others, indurated, and in parts cartila- ginous. Similar changes are detected in the pleurae. Both membranes are often blanched and thickened when the effusion has been of long duration. The cellular tissue in anasarca is some- times merely infiltrated, and its areola? distended by the watery fluid. Portal states, that it is frequently thickened, the cells dilated or lacerated, and the intermuscular tissue indurated and almost cartilaginous. When the infiltration and disten- tion become great, the denser structure of the cutis vera is sometimes penetrated, owing to the separ- ation of its fibres (Bichat); and the epidermis is either raised into blisters,—some of which have been seen unusually large by Morgagni,— or lacerated, the fluid partially or nearly alto- gether escaping through the apertures. Occasion- ally the cellular tissue is much softened and plastic after the liquid is removed; or it is very white or blanched, its appearance suggesting the idea of maceration. 11. (b) The characters of the effused fluid have been remarkably overlooked. They vary extremely, but they generally have some reference to the state of vascular action in the seat of effu- sion. When this has been considerable, the fluid is more or less whey-like and turbid; or it con- tains pieces of albuminous matter, or flocculi, or fragments of a filamentous lymph; and the serous surfaces are often slightly covered in parts with a reticulated lymph, or a muco-albuminous sub- stance. In cases where the effusion has been chiefly owing to an altered state of the blood and diminished vital cohesion of the tissues, the accu- mulated fluid is frequently dark-coloured, turbid, of a dirty or sanguineous appearance. These | conditions are principally found in dropsy of the I pleurae, pericardium, and peritoneum. When the disease occurs slowly, and is chiefly owing to de- bility, original conformation, or impeded circula- tion, the fluid is usually more limpid; and it is frequently remarkably so, being also nearly de- void of animal matter, as in chronic hydrocepha- lus and spina bifida. In some instances, and particularly in ascites or ovarian dropsy, the fluid collected after repeated tapping often assumes very diversified appearances. It has been re- marked of a yellowish, greenish yellow, or greenish colour; or brownish, or even nearly black, by Morgagni, Littre, and others. It has likewise presented puriform, viscid, gelatin- ous, milky or chylous characters, according to Willis,Morton, Becker, Coste, and Pro- chaska. It has, moreover, been found possessed of a foetid or penetrating odour by some authors now mentioned, and by myself. The milky or chylous fluid is ascribed by several pathologists to rupture of a lymphatic vessel. The puriform and viscid or jelly-like effusion is most probably caused by sub-acute or chronic inflammation. The yellowish or greenish yellow tint is some- 606 DROPSY — Appearances on Dissection. times owing to concomitant jaundice, or disease of the liver occasioning the accumulation of the colouring constituents of bile in the fluids; and the green, brown, or black colour probably arises from the presence of a portion of the colouring matter of the blood. The offensive odour, as well, perhaps, as some of the above alterations, may be the consequence of the admission of air into the cavity after tapping, and of the super- vention of inflammatory action upon this oper- ation, or of the long retention in a high temper- ature of a fluid containing a large proportion of animal matter, or of both circumstances con- joined. The liquid effused into the ovaria is generally possessed of very different characters from those presented by the fluid found in the pleurae or peritoneum; and that of chronic hy- drocephalus and spina bifida is commonly different from all others, — the liquid found in the ova- rium, and in the brain, presenting, respectively, the opposite extremes of fluidity, or rather of ani- mal matter. As the properties of the fluids are different not only in the several seats of the effu- sion, but also according to the states of vital action accompanying it, but little importance can be at- tached to the results of chemical analysis, unless they be derived from an extensive and diversified series of cases. These obtained by Dr. Marcet are not materially different from those furnished by Bostock, Barruel, and Berzelius, who found that all the specimens of fluid contain nearly the same saline ingredients as the serum of the blood; and that the chief difference consists in the quantity of animal matter, chiefly albumen and incoagulable mucus (the osmazome of Berze- lius and Barruel) they furnish. The follow- ing table is given by Dr. Marcet: — In 1000 grains of fluid. Specify gravity. Total solid conts. Animil matter. Saline matter. Fluid of Spina bifida ------ Hydrocephalus ------- Ascit s - -——— Ovarian dropsy ------- Hydrothorax ------ Hydrops pericardii ------ Hvdrocele ------- Blister Serum of Blood 1007-0 1006-7 1015-0 1020-2 1012-1 1014-3 1024-3 1024-1 1029-5 ii-T 9-2 33-5 26-6 33-0 8.1-0 10 )-0 groins. 2-2 112 25-1 18-8 25-S 71-S 90-8 grain.. 9-2 8-08 8-4 8-0 7-8 7-5 8-5 8-1 9-2 12. B. The lesions of the viscera which are connected with the production of dropsies, include almost every variety of which they are susceptible. The heart, its valves, and membranes; the blood- vessels, particularly the veins and lymphatics; have presented, in different cases and states of the disease, nearly every alteration described in the articles on the morbid anatomy of those parts. To these I must refer; but here may add, that the absorbent vessels have been found varicose and otherwise diseased, and the glands in the vicinity of the blood-vessels indurated and en- larged,byM0RGAGNI,M0RTON,SoF.IWMERRING, Haase, Assalini, Bichat, Mascagni, and Hodgson. The frequency of inflammatory ap- pearances in the inner membrane of the arteries, and the presence of ossific deposits in them and in the aorta, have been remarked by Hoffmann, Franck,Bader, and myself. The respiratory organs, the liver, gall-bladder, and spleen, pre- sent, in different cases, all the appearances de- scribed in the articles on these viscera. As respects the liver, it may be observed, that those changes and morbid productions which interrupt the circulation through the ramifications of the vena ports, as remarked by Dr. Bright; also the nutmeg-like state of its substance, obstruction of the branches of the hepatic duct by inspissated bile and cholesterine, and calculi in the gall-blad- der; are the most common lesions. 13. The next important changes are detected in the kidneys. Morgagni gives a case from Piccolhomini, in which one of them being la- cerated from the presence of calculi, the urine flowed into the abdomen. Ribe (Schwed. Ab- handl. b. xiv. p. 47.) found them scirrhous; and Hufeland met with numerous hydatids contain- ed in cysts formed in their substance. Instances, however, were few, in which disease of the kid- neys was mentioned by authors in connection with dropsy, and, when noticed, it was in a very vague and unsatisfactory manner, until Dr. Bright furnished numerous proofs of the fre- quency of lesions of structure in these organs, and described their various forms, and relations to dropsical effusions. The first form which he par- ticularises, seems to consist of wasting of the structure, and diminished vascularity and firmness, of the kidneys, which are of a yellow mottled appearance externally ; their internal structure being also yellow, slightly tinged with gray, and the tubular portions of a lighter colour than natural. They contain no morbid deposit. This change is connected with a cachectic habit of body and debility; the urine being only slightly coao-ulable. The second form is that in which the whole cortical part is converted into a granulated texture, with a morbid interstitial deposit of an opaque white substance; giving, in its earliest stages, when the tunic is taken off, an increase of "the natural fine mottled appearance of the organ ; subsequently, with innumerable specks strewed over its surface, and distributed through- out its whole cortical substance, and with defi- ciency of its firmness. At a later period, the granulated texture shows itself externally, occa- sioning irregular projections of the surface, the organ being generally somewhat enlarged. In the third form of disease, the kidney is quite rough and scabrous, and its surface rises in nu- merous projections, not larger than a pin's head, of a yellow, red, and purplish colour. Its shape is often inclined to the lobulated; it is nearly of a semi-cartilaginous hardness, and it gives great re- sistance to the knife.. The tubular portions are drawn near to the surface, every part of the organ appearing contracted, and less interstitial deposit being present than in the foregoing variety. Dr. Bright connects these two varieties with coagu- lable urine; and thinks that, as the one appears to pass insensibly into the other, they are com- monly grades, or stages of the same change. Besides these, there are other lesions of the kid- neys found in dropsies: as preternatural softness; obstruction of the tubular structure, by a white deposit resembling small concretions; scrofulous matter infiltrated or deposited in the cortical sub- stance, and in the interstices between the tubuli; and, indeed, most of the lesions described in the article Kidneys. It is very justly remarked by Dr. J. Gregory, that disease of these organs ia chiefly found in those dropsical patients who are of a strumous diathesis, or who are addicted to DROPSY — Pathological States which occasion it. 607 spiritous liquors. The uterus and ovaria often present numerous lesions of structure, but none that are especially connected with dropsy, except- ing those accumulations of fluid which sometimes take place in the latter organs, and which can scarcely be considered as a species of this disease. Various morbid appearances are also found in the omentum and mesentery, particularly in Ascitis. (See Dropsy of the Abdomen.) 14. iv. Of the chief Pathological States occasioning Dropsies.—The lesions, to which dropsical effusion has been imputed in modern times, have been too generally those al- terations of structure either preceding or attending it. But, although these are manifestly important agents in its causatim, yet they are not the only agents, for we very frequently find them in their most fully developed forms without any effusion. Of the numerous remote and pathological causes enumerated above, there is none, which will singly produce dropsy. And, perhaps, in no other disease is a greater concourse of causes re- quisite to its appearance, than in this. In recent times, the changes of structure have been investi- gated, somewhat to the neglect of vital condi- tions or manifestations; and the former has been too generally looked upon, in respect of the diseases now under consideration, as proximate causes, instead of being viewed as concomitant lesions resulting from anterior changes implicating the functions of life, in one or more of the systems and organs of the frame. The association, how- ever, of these lesions should not be overlooked ; and the share which each may have in augmenting or perpetuating the other ought to be kept in view, but with a philosophic reference to anterior conditions. 15. Up to the end of the last century, dropsies were considered as essentially depending upon obstructions or debility ; although some among the ancients, particularly Hippocrates, admitted the propriety of bleeding in some cases. Stoll, Strak, Brambilla, Schmidtmann, - J. P. Frank, and Grapengiesser, at the epoch now alluded to, inculcated the frequent inflamma- tory origin of these diseases. Wells, Black- all, Abercrombie, Stoker, and Ayre followed in the same track ; and, excepting a slight disposition to carry this doctrine too far, contribu- ted to the advancement of this branch of medical knowledge. At present it is generally admitted that dropsy may arise from sur-action, or sub- action,— from general or local plethora, as well as from obstructed circulation,— from deficient excretion, and from excessive evacuations render- ing the blood thin or watery. The numerous changes detected in connection with aqueous effu- sion, and allowed to favour both it and the accu- mulation of the fluid, may be resolved into a single proposition, viz. increased exhalation and dimin- ished absorption, which comprises all the views promulgated on the subject, the matter chiefly in dispute being as to which of these changes is the accumulation of fluid chiefly owing. It has been attempted to settle the point by experiment and post mortem research. But a matter purely of function — lesions so dependent on vital action and structural cohesion as effusion most undoubtedly is in many cases, however associated, or otherwise dependent upon organic change — cannot admit of a satisfactory elucidation in this manner alone. [ 16. Those who favour the doctrine of increased exhalation argue, that this change usually follows excited action, or irritation of serous surfaces, or relaxation of the exhaling pores, or this latter state associated with increased action of the larger vessels ; that the appearances of the fluid and the constitutional symptoms indicate the ex istence of excited action ; and that absorption is not diminished, is shown by the increasing ema- ! ciation attending the effusion, and by the fact of | this function being generally augmented with the progress of debility. The believers in diminished | absorption contend that, when the agents of this function — either lymphatics or veins — are ob- structed, an accumulation of serum takes place in the parts beyond the obstruction ; that when plethora, general or local, exists, absorption is diminished, as shown by the experiments of Ma- I gendie and Fodkra ; and that, as vascular ful- ness and action are removed, this function becomes restored to its natural activity. That the balance of function — of exhalation and absorption — is broken, is very obvious; but the question is, to which is the fault chiefly attributable ? It is evi- dent that exhalation preponderates over absorption, in all cases where vital action or vascular plethora is increased ; and that, on the other hand, dimin- ished absorption chiefly obtains where the venous or lymphatic circulation is either impeded or ob- structed. These propositions are proved by experiment, and confirmed by repeated observation and numerous pathological facts. So that, instead of contending as to which of these functions is chiefly disordered, it would have been more cor- rect to admit that either may be more or less af- I fected in different cases and forms of the disease, according to the states of vital energy and the nature of concomitaut organic change. Conform- ably, therefore, with these facts, rejecting all exclusive doctrines, and following nature as closely as I am enabled to interpret her actions, I believe that dropsy may arise as now stated, as more precisely expressed in the article Disease | (§ 94.), and as will be more particularly described in connection with lesions of vital manifestation and of structure. 17. In considering the pathological states oc- 1 casioning dropsy, the conditions of vital action appear equally important with structural change, the more especially as the effusion, even where the latter is the most obvious, depends as much upon the former as upon it; alterations of vital manifestation giving rise to both the change of structure and the effusion, whether or not the ef- fusion be a concomitant or a consecutive result. This consideration has so forcibly influenced the ablest writers, as to induce them to arrange the forms of this disease with strict reference *o it. Thus they have been divided into the acute and chronic, the sthenic and asthenic, the tonic and atonic, the active and passive, the inflammatory and non-inflammatory or leucophlegmatic, and into the idiopathic and symptomatic, or the pri- mary or secondary — as they proceed directly from their external causes, or from some vis- ceral disease. These forms are met with in all the seats of dropsy, but in different degrees of frequency. The acute, sthenic, or active state — the effusion consequent upon increased deter- mination and excited action — occurs most fre- quently in the ovaria and brain, and next in the 608 DROPSY—Primary or Idiopathic. pleurae, poricardium, cellular tissue, and perito- neum. Although these states are nearly allied to, they are not identical with, the inflammatory variety of dropsy, which is also most common in the former of these situations. Idiopathic or primary dropsy very generally assumes these states, being connected either with plethora, with increased determination, or with inflammatory action, the augmented exhalations supervening to, and promoting the resolution of, its acute or early stages. This connection will, therefore, be kept in view in the following remarks. 18. A. Primary or Idiopathic Dropsy.— (a) Acute dropsy,or effusion from increased action (the Sthenic, Tonic, Acute, Active, and Inflam- matory, of authors ; the Augmented Secretion of Irritation of Dupuytren and Breschet ; the Hydrophtegmasiee of M. Rayer ; a form of Hy- percrinia or augmented secretion, by M. An- dral). Tissot, Gf.romini, and Bouillaud consider this form of disease to be intermediate between healthy exhalation and inflammatory action ; and Dr. Parry, that it is the result of in- creased momentum or determination of the circu- lating fluid to the seat of effusion. That it often originates in vascular excitement of the part chiefly affected, and is frequently connected with general, relative, or excrementitious plethora, have been fully demonstrated. But the vascular excitement, and especially the injection of the capillaries usually accompanying it, is often dissipated, either par- tially or altogether, soon after the effusion it occasions has become considerable ; and but little remains of the vascular action, which may have approached the inflammatory state at the com- mencement, or of its usual results, but the unab- sorbed fluid.— As soon as the vital tonicity of the exhaling vessels or pores become even partially exhausted, or the vital cohesion of the serus or cel- lular tissues diminished, even the natural momen- tum of the circulation in the larger vessels will be sufficient to produce or keep up a morbid increase of the exhalation. 19. v. The exciting causes of acute dropsy are suppression of the perspiration and of any of the natural secretions and discharges, repulsion of the exanthemata and acute eruptions, and the usual onuses of inflammatory diseases. It is often con- sequent upon scarlatina, and the puerperal states ; or connected with inflammations, particularly of the viscera invested by serous membranes ; and with sub-acute inflammation or active congestion of the central parts of the brain, the substance of the lungs, the pleurae, the pericardium, the uterus, and the ovaria. It occurs most frequently in the young and comparatively robust; and is either an idiopathic disease, as I have here chiefly consider- ed it, or a termination of a morbid state nearly allied to inflammation, or a consecutive or symp- tomatic malady, as when it is preceded or attended by lesions of some adjoining or remote viscus, in which form it will be considered in the sequel. 20. p. Progress.— Although acute dropsy gene- rally appears suddenly and increases rapidly, yet various symptoms of disorder precede those depen- dent upon the effusion. The preliminary distur- bance is often indefinite ; but a sense of uneasiness, soreness, or slight pains of the parts in the vicinity of, or inclosed by, the cavity about to be the seat of the effusion, with disturbance of their func- tions; more or less derangement of the natural l secretions and excretions ; increased hardness, oi fulness, or frequency of pulse; irregular chilli- ness or febrile phenomena, and a feeling of general indisposition ; often precede, in various grades of severity, and for a longer or shorter time, the pa- thognomonic symptoms of effusion. When these first appear, the pulse is usually hard, full, and accelerated, and the skin hot and dry. There are also restlessness, pains in the back and limbs ; tenderness of the surface of the body, particularly over the chief seat of disease ; loaded or white tongue, thirst; constipated bowels ; scanty, thick, high-coloured urine ; and, if the effusion takes place in the thorax, dyspnoea, cough, and other symptoms of that form of the disease, generally precede rather than accompany it. The febrile symptoms often partially subside in a few days as the effusion increases, whilst the symptoms caused by the accumulation become more and more urgent. The urine, in this form of dropsy, generally furnishes, by heat and acids, more or less of a coagulated albumen, — a fact first insisted upon by Dr. Wells and Dr. Blackall, and imputed by Dr. Bright to disease of the kidneys. There is no doubt of this being a frequent pheno- menon, both in acute dropsy, where there is no evident lesion of these organs, and in other forms of the disease, where they are extensively altered. I have, however, occasionally observed it where there was neither dropsy, nor any disorder of these emunctories ; but it is probably more frequently connected with these disorders, than otherwise. 21. (b) Sub-acute dropsy. — The preceding I may be viewed as the most acute or inflammatory form. Yet there are states of the disease interme- diate between it and that next to be noticed. — u. Those which approach the nearest to the sthenic or acute arise from similar causes, are often preceded by the same indefinite symptoms, and manifest themselves more or less suddenly, but advance less rapidly, than it. Sub-acute dropsy most commonly occurs in the cavities of the chest and pericardium, or in the cellular sub- stance ; and is not infrequently complicated with bronchitis, or with inflammation and hepatis- ation of the lungs. It sometimes follows scarlet fever, or even measles. I met with two cases of it after severe attacks of the influenza of 1833.— | p. Those states of it which approach the asthenic or passive form (§ 22.) are most frequently seated in the peritoneal cavity, or in the cellular tissue, or in both ; are sometimes connected with the puerperal states, or chronic bronchitis ; and are seldom preceded or attended by any fever, increase of temperature, or tenderness of surface: but all the secretions and excretions' are more or less impeded, and some of them are entirely in- terrupted. The urine is only occasionally, or slightly, coagulable, and chiefly in those cases which approach closest to the acute.— y. The sub- acute form of dropsy, especially, may arise from whatever will determine or solicit a greater flow of blood than natural to serous surfaces ; par- ticularly if the tonicity of the exhaling pores, and vital cohesion of the tissue, are insufficient to oppose the momentum of the circulation. 22. (c.) Asthenic or passive dropsy is much more rarely a primary or idiopathic disease than symptomatic of, or dependent upon, the patholog- ical states about to be described. In its primary form, it may be attributed chiefly to relaxation of DROPSY—Secondary or Consecutive. 609 the exhaling pores, and of the serous and cellular tissues, and to increased tenuity, or alterations of the blood existing independently of any consider- able structural change. It is sometimes caused by excessive sanguineous evacuations, or exhaust- ing discharges; by the suppression of secretions; and by a deficient, watery, vegetable, or un- wholesome diet. The dropsy that sometimes prevails among the poor in times of scarcity is generally of this kind. It is usually characterised by a weak, unequal, small, and frequent pulse; paleness of the lips, tongue, and gums; flaccidity of the muscles; anhelation on slight exertion; feebleness of the joints; swellings of the lower limbs, or anasarca attending or preceding the effusion into the cavities of the trunk; an un- healthy appearance of the cutaneous surface; and absence of those symptoms which indicate the existence of visceral obstruction or dis- organisation. The urine does not coagulate by heat or acids. This form of dropsy is usually chronic, and is, in adults, most commonly seated in the abdomen, or in the cellular tissue, or in both; sometimes appearing in these situations, particularly the former, after parturition, when it may assume a less asthenic form than that now described. It occurs most frequently in females, and is occasionally associated with hysteria. I have seen it supervene on chlorosis. In infants it usually takes place in the head, and proceeds from constitutional disposition or congenital vice. 23. B. Secondary or Consecutive Dropsies — Symptomatic Dropsies — Chronic or Passive Dropsies—are of most frequent occurrence. They are sometimes preceded by inflammatory action; are seldom, however, attended by acute, but often by sub-acute or chronic inflammation, or by active congestion. They are usually of long duration, and frequently the effects of complicated organic change, although generally more immediately de- pendent upon some specific lesion. 24. (a) Dropsy from disease of the heart is always preceded, for a long or indefinite period, by symptoms of disease of this organ. When effusion commences, early evidence of it is pre- sented in the countenance, particularly in the morning, in the eyelids; and next in the feet and ancles, in the evening; or in the hands and fore- arm, particularly the left. These partial anasar- cous swellings usually continue a considerable time before signs of the accumulation of water in the chest are manifested, and still longer before any effusion takes place in the abdomen. In some cases, indeed, no fluid is found in this latter situation. The pulse is frequently, but not always, much affected long before any anasarca is observed. When water collects in the face, hands, or arms, after protracted ill-health, and without pulmonary symptoms, disease of the heart may be inferred, notwithstanding the re- gularity of the pulse: but auscultation will detect its nature. Generally, as the effusion increases in these parts, so symptoms of its commencement in the chest or pericardium, most frequently in both, make their appearance. The patient at first requires his head and shoulders more eleva- ted than usual in bed; and at last he cannot lie down, the effusion increasing in the cellular tissue, and extending to several or to all the shut cavities. In some cases, particularly when the disease of the heart is of an active nature, haemoptysis, pneumonia, or pleuro-pneumonia, or congestion, takes place in the lungs in the course of the dropsy, and favours or increases the thoracic effusion. When the cardiac disease consists chiefly of passive dilatation and thinning of the cavities, the effusion is usually also of a passive kind, or attended by vascular and general asthenia, a lowering treatment accelerating a fatal issue. Occasionally the anasarca disap- pears, or is diminished, for some time before death; but the symptoms of the internal accumu- lation of fluid become more urgent. When ob- struction in the valves of the left side of the heart exists, congestion of the lungs, with sudden increase of the effusion into the pleura, not un- frequently occurs, and terminates life by asphyxy. The urine, in this state of the disease, is often without any albuminous coagulum, or with very little: but it may, or may not, exist even in the same case, at different stages of its course. This form of dropsy is very frequently benefited by treatment, or for a time apparently removed; but it as often recurs, until the progress of the primary lesion, and the exhausted vital energies, at last favour nn increased, a more general, or more sudden effusion, often associated with pul- monary congestion, and life is thereby quickly terminated. When the excreting functions are impeded, the effused fluids may, from effete or irritating matters being secreted along with them, act injuriously upon the surface or tissue with which they are in contact; and, in this manner, much of the appearance of irritation or of struc- tural change, observed either in its course or after death, may be superinduced. 25. (b) Disease of the blool-vessels and lympha- tics is often productive of dropsies; but in many instances its seat and nature cannot be determined during the life of the patient, and frequently with difficulty afterwards. — u. The actions of the arteries and capillaries are more or less affected — are obviously increased in acute, and dimin- ished in passive, dropsies; — but the change is one of function rather than of structure. There are, however, few cases of the chronic or passive forms of the disease met with in advanced age, where the arterial system is entirely devoid of structural lesion. But when we consider the frequency of alterations in this system in old age, it becomes a question whether it be connected with effusion, otherwise than as both may be coincident results of anterior disorders. Some French pathologists, however, believe that the simple retardation of the circulation, occasioned by structural change in the arteries, favours effu- sion into the cellular tissue and serous cavities. 26. p. In respect of disease of the veins, it may be inferred a priori, and pathological facts have confirmed the inference, that obstructions of them will occasion dropsical effusions, unless a collate- ral circulation be established sufficient to prevent extreme congestion of the vessels below the part where the impediment exists. This position, acknowledged since its demonstration by Lower, has been frequently illustrated by the details of cases. Raikem found, in two instances, anas- arca of the lower limbs, fibrinous concretions obstructing the vena cava and internal iliac veins. Morgagni observed a similar state of the extremities from a tumour which pressed upon these vessels; and attributes, in some cases, 610 DROPSY — Secondary or Consecutive. dropsy within the head to pressure upon the supe- rior vena cava. Haller states, that compression of the jugular veins has produced dropsy of the ven- tricles and membranes of the brain. Laennec found obliteration of the vena cava in a case of ascites and anasarca. I have seen, in two cases, enormous distention of the thigh and leg, from the pressure of a psoas abscess upon the iliac vein; and analogous facts are recorded by Hodgson, D.Da- vis, BoUILLAUD,VELPEAU,MECKEL,andLEE. Organic change about the right side of the heart, or tumours pressingupon the thoracic portion of the vena cava, will obviously produce a similar, but more general effect. And I believe, with several pathologists, that congestion or engorgement of the large veins, from deficient vital power, partic- ularly if it continue for any time, will, independent- ly of mechanical obstruction, be sufficient to occa- sion both increased effusion and accumulation of fluid, owing—1st, to impeded circulation, conse- quent dilatation of the smaller vessels, and escape through the pores of a part of their more fluid con- tents; and, 2d, to diminished absorption, which M. Majen die has shown by experiment to exist in parts whose blood-vessels are inordinately conges- ted. If we allow, with this physiologist, and with several others, who have furnished evidence in recent times, that the veins exert an absorbing function, either directly by their radicles, or by lymphatic vessels opening into them, we must necessarily admit that any obstruction, vital or structural, of the venous circulation, will be fol- lowed by an accumulation of fluid in parts beyond the seat of obstruction. 27. y. Diseases of the lymphatics, both function- aland organic, have been viewed, as stated above, as causes of dropsies. It is obvious that little be- yond the evidence of analogy can be advanced in favour of impaired function of these vessels: but when we consider that many of them open into veins, without passing through glands, we may admit that they will experience the same modifi- cations of function as those vessels with which they are thus intimately connected. And when we reflect on the various circumstances calculated to retard or to entirely obstruct the circulation in the lymphatics passing through glands, and con- veying their fluids into their principal trunks, the admission of impaired function, in some cases, cannot be unreasonable. Of this species of lesion, it is obvious that post mortem research can furnish no positive proof: but of structural change direct evidence may be advanced, although the diffi- culty of obtaining it, even in cases where it may exist, will necessarily diminish the amount. It has been considered by several of the authors mentioned above (§ 26.), that rupture of the lymphatics; by Morgagni, Assalini, Bichat, Soemmerring, &c. that a varicose state of these vessels; by Scherb and Saviard, that concretions formed in their principal trunks; by Haase, Boyer, Hunter, Cruickshanks, Soemmerring, Mascagni, &c. that compres- sion of either them or their glands; by most of the authorities now named, that obstruction, de- struction, or extirpation of these glands; and, lastly, by some of them, that inflammation of the lymphatics, may severally be followed by drop- sical accumulations. On the other hand, cases have been adduced by Morton, D. Monro, Cullen, A. Cooper, Bichat, and Laennec, in which the principal lymphatic trunks were ob- structed without any collections of fluid having been formed. —D.Monro andM.Dupuytren tied the thoracic duct in the lower animals, but dropsy was not the consequence; whilst Mr. Cheston found it obliterated in a case of anasar- ca. I therefore infer, that alterations of these vessels either may, or may not, be the principal pathological cause of the accumulation of fluid; that, in respect of these species of lesions, as well as of others, additional changes are frequently re- quisite to the production of effusion; and that, in many instances where disease of these vessels has been found in connection with dropsy, it has been rather a coincident effect of functional or structu- ral change, or of both, in some vital organ, than the chief source of the collection of fluid. From what has now been stated, it may be concluded, that opinions as to the exclusive operation of any one set of vessels in producing symptomatic drop- sies are altogether erroneous, and that either of them may be concerned in the result, more espe- cially the veins. 2S. The fluid collected in dropsy from ob- struction in the circulation differs from the serum of the blood chiefly in containing much less al- bumen. It is usually limpid, inodorous, either colourless or of a citron tint; and, in some instan- ces, when the obstruction has occurred suddenly, it is slightly coloured by the escape of a few of the colouring particles of the blood. The parts containing it are commonly free from any mate- rial change, excepting in the more chronic cases; and it often collects in very considerable quantity, before much disorder referrible to the accumula- tion is complained of. The symptoms will ne- cessarily vary with the seat and rapidity of the collection, and the parts primarily or consecutive- ly affected. The diagnosis of effusions depend- ing upon disease of the circulating vessels is very difficult in all cases, and nearly impossible in many. When it occurs in the strumous dia- thesis, or early in life, or is connected with, or consequent upon, swellings of the lymphatic glands, lesions of the lymphatic system may rea- sonably be inferred; and when it commences as a local oedema, or is limited to a single limb, or continues in the lower extremities without any signs of disorder referrible to the large cavities, the obstruction of a considerable venous trunk may be inferred. If it appear very slowly in the lower extremities, and increase very gradually, and be attended by a slow, or unequal, or irregu- lar pulse, great coldness of the limbs, with. or without discolouration or sores of the legs, partic- ularly in aged or gouty persons, the arterial sys- tem will very generally present structural change, as ossific deposits in some part of its course. 29. (c) Dropsy connectedwith disease of the lungs. —Either hydrothorax or anasarca, or both, may occur in consequence of pulmonary affection, or merely as coincident effects of the same causes; and iu many instances effusion may take place in the pericardium, in addition to the other forms of dropsy. The acute states of anasarca are not infrequently connected with inflammation, con- gestion, or hepatisation of the substance of the lungs, or with acute bronchitis, particularly after exposure to cold and moisture, or after scarlatina or measles. In many of these cases the pulmonary affection is somewhat obscure, the symptoms DROPSY — Secondary or Consecutive. 611 being imperfectly developed ; and, unless auscul- tation be used, is liable to be overlooked or mis- taken. Dropsy from chronic bronchitis generally supervenes and proceeds much more slowly than that which is connected with the acute diseases now mentioned, but it usually appears in the same manner; the face, particularly the eyes, and upper extremities, first becoming cedematous, and subse- quently the ancles. When any aggravation of the bronchial affection occurs, or if the inflammation extends to the substance of the lungs, the dropsical effusion often increases rapidly. After repeated exasperations of the pulmonary disease, with occa- sional amelioration during summer, in the more prolonged cases, the anasarca becomes more and more general, and at last effusion takes place into the pleurae, the pericardium, the cellular sub- stance of the lungs; less frequently into the peri- toneum; and in some instances into the ventricles, or between the membranes of the brain; and the patient is more or less suddenly cut off. 30. As fluid is effused into the pleura?, or cel- lular parenchyma of the lungs, difficulty of lying down, and dyspnoea, come on and increase; and as it collects in the pericardium, irregularity of the pulse, palpitations, anxiety, oedema of the countenance, fulness of the jugular veins, &c. supervene. If it accumulate on the brain, stupor, coma, paralysis, or apoplexy, takes place. Dropsy occurring in the latter stages of tubercular con- sumption or chronic pleurisy is generally confined to the lower extremities. It sometimes, however, extends more generally, and occasionally more or less fluid is effused into the cavities of the chest. 31. (d) Dropsy from disease of the liver and spleen.—The ancients imputed dropsy more to the liver than to any other part; and during the fif- teenth and sixteenth centuries, this organ was generally considered as being always its cause. Warmbold, Pezold, Vater, Bianchi, and others, however, showed that it was sometimes free from alteration, even in ascites; and more recent and precise research has proved that it is often not materially changed; and that, in many cases of dropsy, where it has presented certain alterations, disease was likewise found in other viscera, to which the effusion might be re- ferred with greater justice than to the hepatic lesion. But collections of fluid are very fre- quently formed in the last stages of most chronic diseases of the liver, especially in those which impede or obstruct the circulation of the vena porta. As to the nature of the lesion, very im- perfect, or hardly any, knowledge can be obtained during life, or even previously to the effusion, unless as to the existence of enlargement, and sometimes of abscess, which may generally be as- certained by careful examination and percussion. 32. When, however, the dropsy has been pre- ceded, for a long period, by dyspeptic symptoms, particularly by flatulence, uneasiness in the sto- mach after a meal; by pain or tenderness in the right hypochondrium, below the right shoulder- blade, or at the top of the shoulder; by short, dry cough, and the usual signs of chronic disease of the liver, more particularly by the projection of the edge of the organ below the cartilages of the false ribs; by jaundice; light or clay-coloured stools; scanty red or high-coloured urine, de- positing the lithic acid sediment; and by slight evening fever; the accumulation may be imputed to the liver, the disease of which, and its attend- ant symptoms, being frequently of very long duration before any collection forms. The dropsy usually appears first in the ancles, towards night; or in the abdomen, occasioning slight fulness; or nearly at the same time in both. The urine is then more scanty; and sometimes becomes dark, muddy, turbid, or thick. The skin is often harsh or dry, the bowels constipated, and thirst increased. The progress of the accumulation varies considerably. Occasionally the anasarca of the lower extremities and the ascites increase equally and gradually. In some instances, the former proceeds much more slowly than the latter; and, in others, the ascites arrives at its utmost extent without much oedema of even the ancles. In many cases there is great vacillation in the course of each; the one increasing and the other diminishing, or either or both expe- riencing a sudden aggravation, and rapidly reach- ing the acme. Sometimes, the collection in the abdomen advances rapidly, and arrives at the utmost in a very few days, without any attendant anasarca; the bowels being obstinately consti- pated, and the urine nearly suppressed. In these cases, the patient generally complains of much pain and soreness, and frequently of tenderness, of the abdominal parietes — probably owing partly to the rapid distention; and possibly, also, to the action on the peritoneum, of the irritating proper- ties of the collected fluid, arising out of the circum- stance of its containing much of the injurious constituents that are usually removed from the system in the excretions which are so completely suppressed. In dropsy from diseased liver, there is seldom any effusion into the serous cavities of the chest or head. But as ascites reaches the utmost, dyspnoea becomes urgent, owing to the diaphragm being carried high up into the thorax; and, during the last few days of existence, slight or low delirium appears, at first during the night; the pulse and breathing becoming rapid and weak, and the general weakness extreme, sometimes with distressing nausea or retchings, and the patient sinks. 33. When dropsy depends upon disease of the spleen, evident enlargement of it generally pre- cedes the accumulation of water, which, as when it arises from disease of the liver, usually forms in the abdomen, and in the lower extremities. In some cases, particularly in those who have resided in warm countries, or in miasmatous lo- calities in temperate countries, the enlargement of the spleen is associated with chronic alterations of the liver; aud the consequent dropsy is but little under the control of medicine. But when the lesion of the spleen is its chief or only source, it may be removed by treatment, along with the disease in which it originated. When dropsy comes on after repeated attacks of ague, and re- sidence in an insalubrious climate, enlargement of the spleen is often influential in its production, or co-operates with other lesions in causing it. In these cases, change of air is one of the best means of removing it. 34. (e) Dropsy from disease of the kidneys. — It may be stated of lesions of these organs, as well as of others found in dropsies, that they are often the principal pathological causes of the ef fusion, but that they frequently also exist without this effect resulting from them. There can be 612 DROPSY — Secondary or consecutive. no doubtthat every change of structure, to which the kidneys are liable, may be more or less con- cerned in the production of effusion, especially those which impede or interrupt their functions. Of this latter kind seem to be the principal of those so well described by Dr. Bright (§ 13.). Dropsy may arise either from disease of the kid- neys alone — which but rarely occurs, and in which case it usually commences with anasarca, at first affecting chiefly the lower extremities — or from lesions of these organs associated with those of the heart, or of the lungs, or liver. In such complicated cases, the disease of the kidneys may be either primary or consecutive; perhaps, more frequently, the latter. — a. When it is consecutive, the dropsy commences, as already described, in alterations of either the circulating or respiratory systems; the accession of the affec- tion of the kidneys being often distinctly indicated by pains in the loins, sickness, vomiting, occa- sionally purging, and coagulable urine. In some instances, however, renal disease may exist with- out these symptoms being prominent; and coagu- lable urine may be present without the kidneys being particularly implicated. — p. When the renal affection is the primary alteration, the dropsy commences as anasarca; but rapidly ex- tends to the cavities of the pleurae and pericar- dium, of the peritoneum, and not infrequently of the arachnoid. In most of these cases, the symp- toms are more acute, and the progress of the dis- ease more rapid, than in any of the other forms of symptomatic dropsy. This seems attributable to the disease of the kidneys being such as pre- vents them from removing all, or even a large proportion, of the injurious elements constantly requiring elimination from the blood; to the con- sequent secretion of a portion of them in the ac- cumulated fluid; and to their imparting irritating properties to it; whereby it induces inflammatory action in the serous surfaces containing it, with rapid aggravation of all the phenomena, and occasionally a concentration of the malady in one or more of its usual seats. Thus, it is not uncommon to perceive symptoms of pleuritis or pericarditis, or even of peritonitis, to accompany, or even to precede, the more advanced periods of the effusion into the respective cavities; and, as the disease is increased in one or more of these, to observe the disappearance of the fluid from the extremities. In some instances, where the collec- tion has formed rapidly in the cavities of the chest, either preceded or attended by acute symptoms referrible to this situation and its con- tained organs, not only the anasarca, but also the ascites, where one or both have previously existed, has partially or nearly altogether disap- peared, the rapid effusion into these situations soon terminating existence. In other instances of this form of dropsy, effusion on the brain is superadded to these, and the patient dies comatose. Dr. Bright and Dr. Gregory remark, that there is great proneness to salivation from small doses of mercury in dropsy from diseased kidneys 35. (/ ) Dropsy from disease of the uterus and ovaria may arise either from the pressure they produce, when enlarged, or containing tumours, on the veins and lymphatic glands and vessels; or from the extension of disease from them to their peritoneal covering. I met with a case, in which ascites was consequent upon chronic inflamma- tion of the uterus, the peritoneum covering the fundus having become consecutively affected; and a nearly similar instance, in which the effu- sion into the peritoneum was owing to the sup- pression of leucorrhcea by astringent injections. In this latter case, I inferred that the discharge proceeded from inflammatory irritation of the in- ternal surface of the womb, or of the os uteri, and that the treatment had suppressed the morbid action in these situations, and determined it to the fundus and peritoneal surface; whence it had extended further, and produced effusion into the abdominal cavity. But little anasarca was present in these cases, and that was confined chiefly to the feet and ancles. Ascites may pro- bably likewise follow chronic inflammation of the ovaria, owing to a similar extension of the ir- ritative vascular action to the peritoneum. Ex- cessive haemorrhage from the uterus, and abor- tions, may also produce dropsy, as stated above (§8.). Those diseases which have been generally described as ovarian and uterine dropsies, are purposely excluded from the present view of the subject. 36. Of the Urine in Dropsies.—Owing to the attention that has been paid to this topic in mo- dern times, and particularly since the investi- gations of Wells, Blackall, Prout, and Bright, the state of this secretion has become an important source of information as to the pa- thological conditions giving rise to dropsical col- lections; although, when viewed alone, much less dependence can be placed upon it. Dr. Wells found that the urine was more or less coagulable in the dropsies consequent upon scar- latina, and even from the exhibition of mercury ; and that this sypmtom was most frequent in anasarca, it having been remarked in twenty-four cases out of thirty-seven. Dr. Christison and Dr. I. Gregory also remarked it most commonly in this form of dropsy; and my experience ac- cords with theirs. I have seldom seen it in ascites. Dr. Blackall considered it as an at- tendant upon the acute form of the malady; and Dr. Prout, as an indication of irritation. Dr. Bright's cases prove its connection with the more advanced states of the changes of the kid- neys he has described, independently of the existence of acute or sthenic vascular action. Several physicians have remarked this state of the urine in other diseases, unconnected with lesions of the kidneys; but admit its frequency in such circumstances, as well as in acute dropsies. I have often observed it in acute diseases of child- ren, where no alteration of the kidneys existed; and I believe it is not uncommon after the ex- anthemata. The above writers have also no- ticed a less specific gravity of albuminous than of healthy urine. As to the dark brown colour which this urine frequently presents in dropsy, the inference of Dr. Bright, that it arises from the red globules of the blood, seems to be correct. The presence of albumen may be ascertained either by boiling, or by the nitric or muriatic ascids, alcohol, the ferro-prussiate of potash, or corrosive sublimate. The last re-agent is, upon the whole, the best. The opinion of Dr. Pkout, as to the value of albuminous urine as a symp- tom, will be adopted with advantage; namely, that we ought always to be aware of its pre- sence, as, taken along with the others, it may be DROPSY — Treatment of Primary. 613 occasionally useful in directing our judgment of the nature of the disease; but that, in the pre- sent state of our knowledge, it does not indicate any particular remedy or mode of treatment. 37. v. Prognosis.—The prognosis in dropsies will necessarily depend on their form and origin; on the extent and complication of the structural changes occasioning them, the state of vital mani- festations, and the habits and age of the patient. — (a) Acute and sub-acute dropsies are generally much less dangerous than the symptomatic, par- ticularly when occurring in young persons and in tolerably sound constitutions; but concomitant circumstances, more especially their association with pulmonary disease, and the nature and ex- tent of that disease, will greatly modify the opin- ion to be formed of the immediate or ultimate result. The form of dropsy which occurs after scarlatina or measles is much more curable than any other. Asthenic dropsy, from excessive eva- cuations or haemorrhages unconnected with struc- tural change, or that from insufficient or unwhole- some diet, generally admits of cure.- 38. (b) Consecutive or symptomatic dropsies seldom are permanently removed. Those arising from organic change of the heart may be remedied for a time, but they generally recur again and again; judicious treatment frequently prolonging life, nevertheless, for several years. When the effusion proceeds from disease of the lungs, the prognosis will be formed with strict reference to it; and, on the whole, will be less favourable than in the foregoing. The same remark applies to dropsy from changes in the vessels. Accumula- tions of fluid from organic lesions of the liver are but little under the control of medicine, and generally terminate fatally sooner or later. Oc- casionally, however, exceptions occur; and much relief is often obtained for a considerable time. When the malady depends chiefly on enlargement of the spleen, a more favourable result has fre- quently been obtained. Dropsy from disease of the uterus and ovaria seldom terminates favour- ably. And it would appear that effusions from structual lesions of the kidneys are the most ra- pidly and certainly fatal. 39. II. Treatment. — It will be obvious to every experienced practitioner, that the distinc- tions made above are merely the more prominent features by which the malady maybe recognised, where the acquaintance with it is imperfect; but that there are numerous other shades of character which deserve to be known, and by which he will be in some measure guided in practice, that scarcely admit of description. Of this kind more especially are those ever varying states of vital power, and grades of vascular action, which de- mand certain indications of cure, or different modifications of treatment, as imperatively as any well-ascertained alterations of structure. There are, perhaps, few diseases that require in the treatment a stricter reference to the conditions of vital power, in connection with changes of its organic alliances, than those now being considered. To ascertain these conditions, and to act strictly in accordance with them in dropsies, even as re- spects those slighter modifications that can neither be illustrated by examples, nor be made subjects of precept, will tend more to successful practice, than any other object of investigation. 40. i. Of Primary or Idiopathic Drop- 52 sies.—A. Treatment of the Acute.—The first object of investigation will be the state of the dis- ease in relation to its remote and proximate causes, and of the constitutional powers of the patient, comprising every appreciable change in the vital functions, and in the appearance of the soft solids, as indicating modifications not merely in the grade, but also in the kind, of action. By the inferences derived from this source, the practi- tioner will be guided in the appropriation of the means of cure, and in the alterations he may conceive necessary of the measures about to be described.—In this form of the disease, especially if it be associated with congestion or inflamma- tion of the lungs, if the constitutional powers be unbroken, and if it have appeared suddenly or advanced rapidly, a full bloodletting will be re- quisite, and may even be repeated. In most cases, however, local bleeding by cupping will be preferable to a repetition of the venaesection; and in more doubtful cases, the local depletion, if decidedly employed, will be suflicient. If cupping be prescribed, it should be performed on the part opposite to the seat of soreness or pain, or at a distance from it, particularly when the lungs or pleurae are affected. Contemporaneously nearly with depletion, medicine should be taken to act upon the secretions, and equalise the circulation; and, for this purpose, there is, perhaps, nothing superior, in the first instance, to calomel, in a full dose, combined with James's powder, or with a moderate dose of camphor, or with both. In some cases, and particularly in persons who have been addicted to drinking, the calomel will be advan- tageously conjoined with opium. In this class of subjects, general bloodletting must be employed with caution. After one or two doses of calomel, in either of these states of combination, a purgative draught should be exhibited and repeated, and its operation promoted by a terebinthinate enema (F. 149, 151.). Having removed plethora and reduced the increased action, the good effects of counter-irritation will be more readily obtained. The tartarised antimonial ointment (F. 749.), or the pea issue, are upon the whole to be preferred; but they should be employed on the side opposite to that where uneasiness is complained of, or at some distance from the most affected part. What- ever external irritant may be adopted, should be long persisted in. In the course of treatment, calomel or blue pill, with either James's powder or tartarised antimony, should be repeated from time to time, until increased action disappear; or be regularly continued, particularly if the pleurae or pericardium be affected, until the specific mer- curial effects become manifest; when deobstruent and saline purgatives may be prescribed, and then- effects promoted by the occasional exhibition of the enema already recommended. The more cooling diuretics only should be given at short intervals, in order to promote the functions of the kidneys. These will be advantageously associated with diaphoretics. For the former purpose, the supertartrate of potash with borax, the acetate of potass, and the nitrate of potash alone, or with nitric aether, may be used; and for the latter, the camphor julap with liq. ammonia? acetatis, with vinum antimonii tartarizati, or acetum col- chici, and small doses of opium. In this form of dropsy, I believe that all heating diuretics, as squills, juniper, seneka root, horseradish, with their com- 54 614 DROPSY — Treatment of Primary. binations and preparations, are more or less in- jurious, unless vascular action has lapsed into a state different from the sthenic form with which it commenced. With this impression, I have usually preferred those that are the most sedative and refrigerating, especially foxglove, colchicum, the wine of tobacco in small doses, and the spiritus aetheris nitrici, as long as any evidence of increas- ed action remains. 41. B. Of Sub-acute Dropsy.—Those interme- diate states of the disease, between the acute and the passive — between the sthenic and asthenic forms—will necessarily require means appropriate to the grade of action they may evince. In the more acute cases, local depletions, and the rest of the treatment described above, will be most effica- cious. In these, the judicious exhibition of deriv- atives and purgatives, followed by diaphoretics and diuretics, constitute the chief means of cure; and, when this state of the disease occurs after scarlatina or measles, or in connection with bron- chitis, digitalis, the preparations of antimony with opium, and the warm or tepid bath, in addition to these medicines, and followed by change of air, will prove of essential benefit. In the more sthenic cases of the sub-acute, as well as in the acute, disease, when it arises from suppression of the perspiration, or of the exanthemata, the warm or tepid bath, or medicated baths consisting of emollient decoctions, &c, or containing the sul- phuret of potash, or the sub-carbonate of soda or of potash, will be serviceable, when employed after sufficient sanguineous and alvine evacua- tions. In the less active states of the disease arising from the same causes, particularly from suppressed eruptions, the application, and, occa- sionally, the repetition, of a large blister, or of mustard poultices, or of warm terebinthinate epithems, at a distance from the seat of effusion, or of irritative action, where the existence of this latter is inferred, will frequently be productive of benefit. In those cases which approach the pas- sive or asthenic character, or in such of the above which may lapse into it, owing to neglect of treatment, or to a too active treatment relatively to the nature of the case, or to constitutional fault, the means that will be advised for the form ofthe disease which is thus characterised (§ 42.) should be employed. It will sometimes occur, especially in the intermediate or more doubtful cases, and even also in the acute, that the more antiphlogistic means will be productive of little or no benefit, or will even appear to aggravate the symptoms, although their exhibition seemed clearly indicated. I have generally observed that the practitioner has been misled by the great frequency of the pulse, which he has mistaken for a sign of in- creased or sub-acute action, instead of viewing it, when it is at the same time soft, small, and easily compressed, and when it is connected with other signs of depression of vital power, as evi- dence of great weakness conjoined with increased irritability of the vascular system. In such cir- cumstances, I have found gentle tonics and astrin- gents, with deobstruent laxatives, or with alkaline sub-carbonates; and the moderately stimulating diuretics, more especially the balsamic and tere- binthinate preparations, with camphorated opiates, &c; and, if the pulse be languid, with frictions, actively, long, or frequently employed; prove very beneficial. Sub-acute or acute dropsies, I appearing after the suppression of the hsemorrhoi- dal discharge, require, after moderate bloodletting, the active exhibition of hydragogue purgatives; and the same states of disease connected with suppressed menstruation are most benefited by a nearly similar treatment, with the addition of the sub-borate of soda, continued regularly for some time. In some cases of the less sthenic state of sub-acute dropsy, the internal and external use of the nitro-muriatic acids; or a well-regulated course of Bath waters, with frequent changes of air; and in others, the artificial waters of Carlsbad, Ems, or Marienbad; and where the bowels re- quire frequent assistance, the Seidschutz waters; have proved very serviceable. 42. C. Treatment of Asthenic or Passive Drop- sies.— In cases where the debility is general, at the same time that vascular action is either languid, or weak—notwithstanding that the pulse is frequent—and the vital cohesion of the cellu- lar and serous tissues is diminished, tonics with the mineral acids, especially the infusion of cin- chona or the sulphate of quinine, should be pre- scribed. Where a cachectic habit of body is manifest, quinine will probably occasion heat and feverishness. In such cases, it will be necessary to associate the vegetable tonics with deobstruents and laxatives; to exhibit the blue pill or Plum- mer's pill in small and frequent doses, with taraxacum, or the compound decoction of sarsa- parilla, the mezereon having been left out. In many of those doubtful cases of this form of the disease, where it is difficult to determine whether it is primary, or associated with obscure lesion in the secreting substance of the liver or kidneys, some advantage will be derived from minute doses of the oxymurias hydrargyri in large quantities of the decoction of sarsaparilla, or of any of the species ofthe smilax. I have likewise, in such circumstances, found great service from iodine,par- ticularly the hydriodate of potash, and the iodur- etted solution of the hydriodate, in smaller and much more frequent doses than areusuallydirected. 43. When this form of dropsy has arisen from excessive losses of blood, or has supervened on chlorosis, the chalybeate preparations, with cha- lybeate mineral waters, or the artificial Pyrmont and Spa waters, will be of the utmost service. But care should be taken to ascertain the non- existence of visceral obstruction before they are resorted to, and to preserve the bowels freely open during their use. When passive dropsy occurs after delivery or abortion, bitter infusions, and vegetable tonics, the decoction of cinchona with mineral acids, occasional purgatives, and the terebinthiuate enema, with frictions of the surface and bandages, will be requisite; and, if it be accompanied with hysterical symptoms, the preparations of juniper, spirit, aetheris nitrici, or other aetherial preparations, with tinct. camphora comp., or small doses of opium, will be of much service. In these cases, the combination of diur- etics with bitter or tonic infusions, and small doses ofthe tinctura camphorae Thebaica (F. 708.), or the tinct. opii camph. (F. 728.) will generally be advantageous. 44. ii. Treatment of Consecutive or Symptomatic Dropsies.—It is obvious that the intentions of cure in this class of dropsies should have strict reference to the nature of the organic I lesions concerned in the production of effusion, DROPSY—Treatment of Consecutive or Symptomatic 615 and to the state of vital energy and structural cohesion; and that they should comprise the following objects.—1st. To remove these lesions, and if this cannot be accomplished, to retard their increase, as the chief means of diminishing the effusion ; — 2d. To promote the absorption of the fluid accumulated; — and, 3d. To support the constitutional powers; as being necessary both to the due operation of remedies, and to the exer- tion of that vital resistance which guards the structures against the impression of hurtful agents, whether generated within the system, and acting intrinsically, or invading them from without. 45. A. Of dropsy consequent on disease of the heart. — It will be important to ascertain, as cor- rectly as the rational and auscultatory signs will enable us, the nature and seat of the cardiac lesion, in connection with the seat of effusion, and its characters in respect of activity. If obstruc- tion to the circulation be seated in the left side of the heart, there will very probably be asso- ciated with the effusion, congestion of the sub- stance of the lungs, which will aggravate the hydropic symptoms, and render depletion the more necessary. Also, if the cardiac disease con- sist, either altogether, or in part, of active enlarge- ment of the parietes of the cavities, the dropsy will present a sthenic character, and require antiphlogislic remedies ; but if the lesions be chiefly passive, — if there be dilatation with thin- ning or softening of the parietes of the heart,— the constitutional symptoms will possess analogous features, and the disease require an opposite — a tonic, treatment. It will be evident from these facts merely, that, in symptomatic, as well as in idiopathic, dropsy, and even in that connected with impeded circulation through the heart, the strictest reference should be had to the state of vital power and vascular action, as the principal basis of our intentions of cure. 46. If a^jj|teof sthenic action exist, local de- pletion— preferably by cupping; hydragogue cathartics, as elaterium and the croton oil, re- peated from time to time ; or even these inde- pendently of depletion ; and subsequently the use of diuretics, or these at an earlier period where the active and repeated exhibition of purgatives are not well borne ; will frequently remove the accumulation of fluid. In this state of the dis- ease, digitalis is the most efficacious diuretic, especially after local depletions and purgatives, in the more sthenic cases. Debility rather indi- cates, than contra-indicates, the propriety of resorting to it. The infusion is the most certain preparation of this medicine. Half an ounce of it two or three times a day, as usually directed, is a much larger dose than that recommended of its other preparations ; hence the reason of its ac- tivity, its diuretic operation being heightened by the addition of small doses of opium. If a tensive pain iu the forehead, with disturbance of the cerebral functions, come on early after its exhi- bition, it will rarely be of service, or it may even be injurious, as remarked by Dr. Blackall, and it, therefore, should be immediately relinquished. When there is much debility, it should also be discontinued upon the first appearance of an in- crease of the urine. But even great debility is no reason against the use of this medicine, as Dr. Withering has shown ; only the more cau- tion is required in its exhibition. In such cases I have usually combined it beneficially with cam- phor, a small quantity of opium, or with cinchona (F. 859.), and other vegetable tonics and cordials, or with F. 708. or 728. Colchicum is sometimes of service when this form of dropsy assumes a sthenic character, or appears in the rheumatic or gouty diathesis ; but it requires much caution. It is most safe, and at the same time most service- able, when combined with camphor or ammonia, or with the alkaline sub-carbonates, and infusion of cinchona. 47. Wrhen the cardiac disease and its conse- quent effusion are of a passive kind, and especial- ly if the constitutional powers are much reduced, a tonic treatment, in conjunction with stimulating diuretics, is requisite. The remedies of this description already recommended (§ 43.),—the infusion of quassia, with the muriated tincture of iron, and tincture of digitalis ; the compound infusion of angelica, (F. 219.); the decoction of broom tops (F. 75.), with the compound spirit of juniper ; the compound decoction of taraxacum (F. 77.), with tincture of calumba or tartarised iron; and either Formulae 570. 781. 859., or the following, will often be prescribed with be- nefit : — No. 179. R Potassae Sub carbon. £j.; Tinct. cinna- mon. Co. gj. ; Spirit. ./Ether. Nit. 'j.; Infus. Gentiaoae Comp. gj.; Aquae Anethi Jiij. M. Fiat Haustus ter quotidie sumendus. No. 180. R Potass* Acetatis Jss.—9ij.; Tinct. Di- gital! TCJ viij.; Tinct. Opii Tt] v.: Spirit Junip. Comp. 3j. ; Infus. Quassias 3'*-> Aqu^e Pimentae Jiij. M. F.at Haustus ter quaterve in die sumendus. No. 181. R Camphors subacta?, Guniaci Res:nae, aa 3j. i Pulv. Scillae et Pulv. Digitalis aa. ex. xv.; Op i Puri gr. v.; Olei Juniperi TT) vxij. ; Mucflag. Acacia; q. s. M. Contunde simul, et distribue massam in Pilulaa aequales xlviii., quarum capiat binas ter in die. No. 182. R Tinct. Digitalis t[| x.—xv. ; Liquor. Am- monia; Acetatis "ij.; Infus. Cinchonas et Mist. Cam- phorae aa. 3 vj.; Tinct. Camphora-. Comp. 3 j.; et Spirit. Anisi 3 93. M. Fiat Haustus bis quotidie sumendus. 48. B. Dropsy from disease of the absorbing systems — veins and lymphatics.— The difficulty of determining when the effusion is owing to these causes has been stated above, with such signs as sometimes indicate its existence (§ 25. et seq.). In the more limited states of anasarca, and even in ascites, bandages and frictions, assiduously em- ployed, with the internal exhibition of the hy- driodate of potash, or of the other preparations of iodine to be found in the Appendix (F. 234. 723.), have proved exceedingly beneficial in some cases in my practice. The decoction of broom tops with liquor potassae, or this latter in the compound decoction of sarsaparilla ; equal quantities of the sub-borate of soda and supertartrate of potass in the decoctum cydonia, or decoctumguaiaci comp.; the diuretic drinks, in the Appendix (F. 588. et seq.); and frictions with deobstruent liniments (F. 295. 297. 311.), will occasionally be of much service. The sub-carbonate of soda, or nitrate of potash, or both, exhibited in tODic infusions, to which small doses of digitalis are added ; and the infusion of berberis, or the compound decoction of taraxacum (F. 76, 77.), with sub-carbonate of potash or of soda ; or the same alkaline carbonates with the infnsion or mixture of the diosma crenata (F. 231. 396.); may likewise be employed, with a prospect of advantage, from their deobstruent operation. In all cases of this kind, gentle exer- cise in the open air ; the use of the artificial waters of Marienbad, and Eger, or of Seltzer or Seid- schutz ; and strict attention to a moderate, di- 616 DROPSY—Treatment of Consecutive. gestible, and cooling diet; will prove of essential benefit. 49. C. Dropsy connected with pulmonary dis- eases. —The treatment in this complication should mainly depend upon the character of the vascular action, and vital power, and the nature of the existing pulmonary lesion. If active congestion or inflammatory action be present in the substance of the lungs, or in the pleurae, general or local depletions, or both ; the internal use of antimonial preparations with diuretics ; and external deriv- ation, as pointed out above (§ 40, 41.); constitute the principal means. The same treatment is re- quired, with the addition of purgatives, if the effusion be associated with acute or sub-acute bronchitis. In these states of the disease, the heat- ing diuretics, as squills, ammoniacum, senega,&c, ought not to be exhibited. The supertartrate of potash with borax, or with digitalis ; or any of the neutral salts, with liquor ammonia acetatis, the spiritus aetheris nitrici, or the acetic eether ; or the preparations of colchicum with the alkaline car- bonates, or with camphor or ammonia ; are the most appropriate. Iu the chronic and asthenic states of pulmonary disease connected with a similar condition of the system, a tonic treatment is indispensable ; and the warmer diuretics (F. 552. 570. 893.) will generally be employed with benefit, more particularly the balsamic aud terebinthinate preparations (F. 22. 169. 485. 487. 571. 681.827.), and ammoniacum, with the tinct. camphorae comp. (F. 708.), or the tinct. opii camphorata (F. 728.), or the peparations of squills with any ofthe neutral salts, given in the light bitter, or tonic, or diuretic infusions. (See Bronchitis—Treatment of Chronic, §"C.) 50. D. Treatment of dropsy from disease of the liver and spleen.—(a) This form of dropsy is very commonly connected with general debility, and with a cachectic state of the frame. In some cases, the colour, consistence, and vital cohesion of the soft solids are more or less changed, particularly the cellular, serous, and mucous tissues. These cir- cumstances should not be overlooked in framing plans of treatment. Cases of this complication are comparatively rare, that require general or even local depletion. However, when symptoms of inflammation of the liver are present, general and local depletions — the latter at least — should not be omitted. Mercurials should also be em- ployed, especially when the surface of this organ is the part chiefly inflamed ; and occasionally externally by friction, as well as internally; counter-irritation being kept up at the same time. But it is doubtful whether or not these pre- parations are beneficial in the chronic lesions of the substance of the liver. I have generally abstained from prescribing them in such cases, excepting the oxymuriate, in minute doses in the compound decoction of sarsaparilla, or in the preparations of cinchona. More service will accrue from the nitro-muriatic acid bath, or from sponging the surface of the hypochondria, night and morning, with a warm lotion contain- ing these acids, or from the internal use of them. The chlorate of soda may also be taken with ad- vantage ; but I believe that greater benefit will be derived from the hydriodate of potash, or the other preparations of iodine, given in minute doses, and continued for a due period, than from any other medicine. Either the infusion of calumba or of quassia, or the infusion of pine tops ; or the de- coction of genista, or of taraxacum, with the alkaline sub-carbonates, or with the liquor am- monia; acetatis, and spiritus aetheris nitrici ; and the supertartrate of potash with sub-borate of soda, and squills, taken in the form of electuary, with the inspissated juice of the sambucus nigra, will be more appropriate when the liver is organically changed than in the other forms of the disease. The preparations of colchicum and tobacco, parti- cularly the tinctura tabaci composita (F. 742.), may also be given in this complication, but with caution. They have seemed to me most benefi- cial when associated with large doses of the alka- line sub-carbonates, and taken in tonic infusions or decoctions ; as those remedies which depress the vital powers too low are seldom productive of benefit in cases of this description. (See Dropsy —of the Abdomen.) 51. (b) A nearly similar treatment will be necessary when the spleen is enlarged, to that now recommended in cases of organic change of the liver. I believe, however, that tonics of an active kind, particularly cinchona, quinine, the prepa- rations of iron, and the arsenical solution, either conjoined, or alternated with purgatives or diure- tics, are much more necessary in this complication than in that last discussed. All the cases I have seen connected with enlargement of the spleen were consecutive of protracted agues ; and in these, after exhibiting one or two full doses of calomel with camphor, and fully evacuating the bowels by means of the compound infusions of gentian and senna (F. 266.), the above tonics, prescribed as now mentioned, and assisted by frictions over the region of the spleen, were pro- ductive of great benefit. In the case of a patient from one ofthe most marshy parts of Essex, with this complication, the preparations of iodine were essentially efficacious. In this state of the disease, but little or no permanent benefit will be derived as long as the patient continues to reside in a mias- matous locality. In it, also, more than any other form, will advantage accrue from moderate exer- cise, change of air, sea-voyaging, and the use of the Carlsbad or Ems mineral waters, — which, with those of Marienbad, Eger, and Seidschutz, are often of service when the effusion arises from hepatic obstruction. 52. E. Treatment ofdropsy from disease of the kidneys. — Attention has been so recently drawn to this complication, by the writings of Dr. Bright, that sufficient experience ofthe means of treating it has not been yet acquired. I have had an opportunity of treating only three cases.in which these organs were found diseased after death, since the publication of Dr. Bright's work. They were persons of broken-down constitutions, by drinkiug. In one of them the accumulation steadily increased, notwithstanding cupping over the loins, counter-irritation in this situation sub- sequently, friction with stimulating liniments, and various internal remedies, were employed. In the others, these means were of temporary benefit. The supertartrate of potash with jalap, and squills with opium or hyoscyamus, are mentioned by this pathologist as having been the most serviceable in the cases which occurred in his practice. I believe that, in a very great majority of instances where effusion proceeds from this cause, the irri- tating nature of the fluid poured out superinduces DROPSY — Remarks ok Medicines recommended in. 617 inflammation of the membranes and cellular | tissue containing it, and thereby aggravates the disease, and accelerates a fatal issue. That the fluid is possessed of these properties may be viewed as a postulatum; but if it be considered that, when the functions of the kidneys are inter- rupted, excrementitious or serous plethora (see Blood, § 19.) will be the result; and that the watery parts of the blood, which are effused from this cause, must necessarily contain a consider- able quantity of the injurious matters usually eliminated by these organs; the irritating quality ofthe accumulating fluid here contended for will be admitted. In the cases seen by me, consecu- tive inflammatory action appeared in the seats of effusion; and a similar occurrence took place in most of those detailed by Dr. Bright. When this complication is attended by debility or diar- rhoea, the propriety of employing tonics, with diuretics and opiates, as cinchona or quinine with the mineral acids or squills, cannot be doubted; and, when the bowels are constipated, or when diarrhoea is not present, free alvine evacuations by purgatives combined with bitter tonics, which increase their operation, will be productive of benefit. I believe that there are few cases of this form of dropsy that may not admit of the judicious exhibition of strengthening medicines, when a free action is exerted on the bowels; that the diarrhcea and tormina which sometimes accom- pany it, are seldom attended by copious evacua- tions, but require that they should be procured by medicine; that the balsams and terebinthinates, either conjoined with these, or trusted to chiefly alone, or with smalL doses of opium, will prove more beneficial than other diuretics; and that a lowering or antiphlogistic treatment has been too generally adopted, as well in cases of this descrip- tion, as in others where coagulable urine is observed, owing to the mistaken notion that this symptom always indicates inflammatory or sthenic action. 53. F. The treatment of dropsy from disease of the uterus or ovaria will depend upon the state of vital power and vascular action. Al- though very generally evincing an inflammatory character, and connected with suppression of the sexual discharges, yet it is often associated with depressed vital or constitutional power, at least in those instances which have come before me. When, however, it supervenes on chlorosis, it is altogether a disease of debility. Iii the former class of cases, local depletions, cooling aperients and diuretics with gentle tonics; the nitrate of potash and sub-carbonate of soda, with the spiritus aetheris nitrici and hyoscyamus in the infusion of cinchona, or of calumba, or of juniper berries; the supertartrate of potash with sub-borate of soda; the expressed juice of the sambucus nigra and syrup of squills; and frictions with oleaginous or te- rebinthinated liniments (F. 297. 311.); may be se- verally employed; but the treatment should mainly depend upon the presumed state of the primary disease, of the consecutive effusion, and state of vital power. The object, in this form of the disease especially, should be to remove the primary lesion; for when this is accomplished, the effused fluid will soon be absorbed. When the disease follows chlorosis, the preparations of iron, the mistura ferri composita, the sub-carbonate of iron with electuary of senna and oxymel of squills; the preparations of juniper with cinchona, &c, 52* with change of air; horse-exercise, the chalybeate mineral waters, and warm clothing, will generally be efficacious. I had recently a case of this de- scription under treatment, both whilst it was simple chlorosis, and when water had collected in the abdomen and lower extremities. I was sur- prised at its resisting the free use of chalybeate and other tonics; when I found that the patient had entertained a dislike to salt, and to food which contained it, and had long avoided it. The cause of the general and extreme cachexia was now evi- dent: the use of salt was enforced; the chlorate of potash was also prescribed alternately with the pre- parations of iron, and recovery soon took plaoe. 54. ii. Notices of the Medicines recom- mended in Dropsies by Authors, with practical Remarks.—Having, in the forego- ing sections, stated chiefly the results of my own experience, I now proceed to notice, under dis- tinct heads, the means advised by respectable and original authorities for the treatment of this class of diseases. The remedies recommended in the cure of dropsies have usually been directed with the following intentions: — 1st. To remove the state of vascular action, and vital power giving rise to effusion — (a) by refrigerants, comprising vascular depletion and other antiphlogistic reme- dies; (6) by sedatives; (c) by external irritation; (d) by tonics and astringents; and (e) by a com- bination of two or more of these;—2d. To remove obstruction to the circulation, and to promote the absorption and discharge ofthe accumulated fluid — (a) by deobstruents, frictions, and bandages; (6) by purgatives and hydragogue cathartics; (c) by diuretics; (d) by emetics; (e) by sudo- rifics and (/) by various combinations of them;—and, 3d. To evacuate the fluid by surgical aid — (a) by blisters and scarifications; (b) by acupuncturation; (c) by paracentesis. Of these last means notice will be taken when the specific states of dropsy in which they have been employed come under consideration. 55.1st. To remove the State of Vascular Action and Vital Power giving rise to Effusion.—A. By refrigerants, fyc.—(a) Vascular depletion, general or local, or both, has been advised in the acute states ofthe disease from Hippocrates up to the present day; and has been more particularly insist- ed on by Me sue, Bonet, Aasc he im, Schulze, Bruele, Juncker, Stoll, Tissot, Rush, Oberteufter, Grapengiesser, Black- all, Abercrombie, Graham, Venables, and Ayre. The propriety of repeating it has been shown by J. P. Frank, Dr. Graham, and some later writers; although the number of cases that can admit of the repetition of general blood- letting will be comparatively small, and those only in the young or unbroken constitution.—(b) Nitre has been very generally prescribed, not merely as a refrigerant, but as a diuretic. Rush attached some importance to it after venaesection, directing it with spare diet; and Rosier andOfiERTEUF- f e r , with squills.—(c) The muriate of ammonia, in doses of ten grains to a scruple, has been given by me in some cases consequent upon ague with benefit; and is appropriate not only to acute and sub-acute cases, but also to the more passive states of the disease, particularly when taken ia tonic or warm diuretic infusions, and conjoined with ammoniacum.—(d) Low diet has been es- pecially noticed by Tissot and Rush 618 DROPSY — Remarks on Medicines recommended in. 56. B. By sedatives.—(a) Antimonials may be more appropriately considered as sedatives than as diaphoretics, inasmuch as their operation in the latter capacity arises from their sedative influ- ence on vascular action. James's powder and tar- tar emetic are the preparations of this class most to be depended upon, and are sometimes useful in the acute and sub-acute forms ofthe disease, con- joined with calomel, or with cream of tartar. They have been prescribed in such cases by Van Helmont,Sydenham,Mynsicht, and Rich- ter. With squills and saline diuretics, they have been employed by Brisbane and Willich.— (b) The diuretic operation of tobacco is evidently owing chiefly to its sedative influence on the cir- culation. This active substance is indicated in the more acute states of the disease, but it may also be exhibited with tonics and stimulating diuretics, where the debility is more manifest. It has been recommended in the form of powder, infusion, wine, or tincture, by Magninus, Bartholin, Fowler, Neander, GARNETT,and Baldin- ger. Dr. Fowler advises the infusion in gradually increased doses; Garden, its ashes with rhubarb and sulphate of iron; and some Con- tinental writers with camphor in the form of tinc- ture (see F. 742.), which may be added to other medicines. The ashes of tobacco are very fre- quently mentioned by the writers of the last cen- tury, but their operation can depend only on the quantity of vegetable alkali they furnish.— (c) Several ofthe solanaceous order of plants, besides tobacco, have been employed in dropsies, both as the principal means confided in, and in order to assist, by their sedative and diuretic operation, other medicines possessed of less equivocal diuretic properties. The belladonna, the physalis alke- kengi, the solanum dulcamara, the s. somnifrum, and the «. nigrum, have been employed by Stoerk, Baldinger, Stark, and others, with this intention. The hyoscyamus has also been very frequently prescribed, with the view of diminishing irritation and promoting the action of other medicines; but it is inferior to—(d) opium, in this respect, the good effects of which in drop- sies have been particularly noticed by Willis, Arnemann, Brocklesby, Ritter, Baker, and Mason. Its influence in determining and heightening the effects of diuretics has been shown by Lentin and Paris. Doemling always added it to squills; and Leake, to this medicine and cream of tartar.— (e) The lactuca virosa has also been recommended to fulfil the same in- dications with the above by Collin, Durande, and Richter, particularly in conjunction with digitalis—two grains of the extract of the former, with half a grain of the dried leaves of the latter, finely triturated with white sugar, and taken three or four times a day. The foregoing sedatives, as well as the colchicum (§ 80.), will be found very useful adjuncts, and indeed not infrequently the chief means that should be resorted to when the disease is attended with much pain, or with spasms or cramps. 57. C. By external irritation. — It is but rarely that external irritants give issue to a quan- tity of serum sufficient to unload very consider- ably the vascular system: but in the acute, and especially in the sub-acute, states of the disease, after depletions, a judicious use of them is often productive of benefit, by transferring the irritation sometimes occasioning the effusion, from the in- ternal parts. They are applicable chiefly to dropsies of the thoracic cavities, depending upon pulmonary disease, to those consequent on scar- latina, and to ascites. The means by which counter-irritation should be effected is an im- portant consideration. In the states and species of the malady now alluded to, the tartarised antimonial ointment, or issues, may be prefer- red; or blisters may be applied in the more asthenic and rapidly progressive cases. When the effusion seems owing to obstruction of the liver, blisters, several times repeated, over the right hypochondrium, and below the right shoul- der-blades, or rubefacient plasters in the same situation, are sometimes of much service. When the kidneys are apparently affected, they may be applied over the loins, after cupping in that situ- ation; or the tartarised antimonial ointment may be used. In the more sthenic cases, or when the urine is very thick and scanty, it will be preferable to apply fine tissue paper between the skin and the blister, or to dip the plaster in boil- ing water before applying it, in order to prevent the absorption of the irritating principle of the flies. In some cases, scraped horseradish, or the inner bark of the mezereon, will prove excellent counter-irritants; or mustard poultices may be used for this purpose. I have, in several cases, how- ever, seen more benefit arise from the application of a cloth moistened with either of Formulae 296. 300. 311. in the Appendix, or with spirit of tur- pentine, over the seat of disease, than from any ofthe foregoing. The inflammatory irritation they occasion is never followed by unpleasant results, as in the case of blisters, which, in the old and debilitated especially, sometimes produce danger- ous effects if not carefully watched. 58. D. By tonics and astringents. — These medicines are often necessary in some of then- various combinations, even in cases where it is necessary to resort to vascular depletion, and not infrequently after this practice has been employ- ed. Much, however, will depend upon the selec- tion of these medicines, and the mode of exhibiting them, appropriately to the pathological states of the case. The observations already offered will assist the practitioner, with a due exercise of his own discretion, in this important matter. Tonics and astringents are indispensable in all the pas- sive or asthenic states of the disease, associated either with diuretics or with purgatives; and in many of the sub-acute and even acute forms, after the antiphlogistic treatment has been prescribed, particularly when conjoined with cathartics. They are especially indicated where the effusion seems to depend chiefly upon an atonic state of the extreme vessels, and deficient vital cohesion of the cellular and serous tissues, with flaccidity of the soft solids generally. In cases of this de- scription they have been directed by most writers, and even by J. P. Frank and Richter, by whom the inflammatory and sthenic states of i effusion have been so ably investigated. 59. (a) Of the particular tonics that may be I employed, the preparations of cinchona and sul- phate of quinine are the most generally appli- cable. They have been especially noticed by Lentin, De Haen, Broughton, aud Ring. The tn/u»'on or decoction of bark is an excellent I vehicle for the alkaline and saline diuretics, aa DROPSY — Remarks on Medicines recommended in. 619 well as for several purgatives, the action of which it tends to promote. Lettsom gave cinchona with squills; Lyson, with serpentaria, either in tincture or infusion; J. P. Frank, with juniper; Horn, with the balsams or turpentines; and Vogel, with the neutral salts, or sub-carbonates of the alkalies. Where the sthenic diathesis may seem to contra-indicate its use, the infusion will be advantageously associated with the nitrate of potash and sub-carbonate of soda, and with ap- propriate diuretic tinctures or spirits. It may also be given with the mineral acids and aethers, especially the muriatic or sulphuric. The sul- phate of quinine may also be taken in the com- pound infusion of roses, or of orange peel, in con- junction with the sulphates of magnesia, or of potash, or of soda, and any diuretic spirit or tinc- ture.—(b) The infusion of calumba, of quassia, and of gentian, have been exhibited in similar states of the disease, and combined with the same substances, as cinchona. 60. (c) The preparations of iron have been as generally prescribed in dropsies as those of cin- chona; and, as in respect of them, with the object of imparting tone to the minute vessels, and thereby of diminishing effusion, and of preventing its recurrence after the fluid has been directly removed. This class of tonics was much employ- ed by Dover, Black more, Be rgius, Tissot, Grieve, Frank, and Rush. The combination of chalybeates with purgatives is advised by Ried- lin and Thomann. Dover recommended an electuary consisting of the sulphuret of iron, scammony, and crude mercury; of which Dr. Blackall has made favourable mention. Fou- q,UET directed it with sulphur. The ferrum tar- tarizatum and the muriated tincture are the preferable preparations; but the sulphate or sub- carbonate may likewise be used. An electuary containing the tartarised iron, the confection of senna, the inspissated juice of the sambucus nigra, and the syrup of squills, will often prove serviceable in asthenic states of the disease.— (d) The absinthium, in the form either of in- fusion, wine, or powder, was formerly much em- ployed; and was praised by Celsus, Bonet, Hartmann, and many others, particularly when given in conjunction with juniper, or other diu- retics. It has now undeservedly fallen into dis- use.—(e) Of the stimulating tonics, phosphorus has been prescribed, in minute doses, and usually dissolved in oil or asther, by Loebf.l, Gaultier de Claubry, and others: it has likewise been used externally in oleaginous liniments.— (f) Insolation, or exposure to the sun's rays, has been recommended by Celsus and Portal. 61. (g) Several of the astringent tonics have been directed in various combinations. The sul- phuric acid was recommended by Mondschien, Haller, Tissot, Bang, and Hartmann; and was frequently given with the infusion of the bark or ofthe flowers ofthe sambucus nigra, or the in- fusion of quassia, or of cinchona. The muriatic acid was also exhibited in similar states of com- bination by Riverius and Digby. The nitric acid, either alone, or with the muriatic in equal proportions, has been very commonly employed, both internally and externally, by practitioners in the East Indies, in cases depending upon hepatic disease (§ 50.).—(h) The sulphate of copper, in doses of half a grain each, with opium, has been praised by Wright.—(t) In addition to these, the centaurium minus and the inula campana have been noticed by Gruling and others, who have prescribed them in the form of wine or beer; and the prinos verticillatus, by Barton.—(k) The mineral waters of Pyrmont, Spa, Bath, and Tunbridge, have been severally directed in cases for which tonics are appropriate. Dr. Perci- val recommended the natural and artificial waters which contain fixed air. Schenck, Quarin, Gilchrist, J. P. Frank, and several other wri- ters, mention in favourable terms change of air and sea-voyaging. — (/) Most of the ancients, with Fuller,Rush, and some others of the moderns, have insisted on the good effects of active ex- ercise in the open air. When the patient is able to adopt this advice, there can be no doubt of its great efficacy. 62. D. By a combination of two or more of the foregoing plans of cure. — I have already remarked that depletions are not infrequently re- quisite to a moderate extent, in order to remove relative or excrementitious plethora, even al though vascular action may not be increased; and there is often a necessity for the exhibition of tonics at the same time, generally with purgatives or diuretics. The propriety, however, of asso- ciating sedatives with the various antiphlogistic measures noticed above, and counter-irritation with both, in the inflammatory or acute states of the disease, is still more manifest. The com- bination, also, of some one of the sedatives with the tonics or astringents, whether these latter be given alone, or conjoined with one or more diu- retics or deobstruents, is generally found useful, not merely in promoting their operation, but also in relieving the more uneasy sensations which fre- quently occur during the progress of the disease. 63. 2d. To remove Obstructions to the Circula- tion, and to promote the Absorption and Dis- charge ofthe accumulated Fluid.—This indication comprises three objects,—the removal of obstruc- tion, the promotion of absorption, and the augmen- tation of the urinary discharge. These, however, are so intimately connected, that the attainment of the first is generally followed by the second and third.— A. By deobstruents, and the use of frictions and bandages.—These means are ob- viously appropriate to casts of dropsy depend- ing chiefly on congestion of the large veins, or to obstruction either of them or of the lympha- tic system (§ 48.). Many of the remedies which are supposed to act upon the kidneys, operate in some respects by removing obstructions to the venous and lymphatic circulation, and increasing the action of the absorbents. Those substances whjch have been very commonly termed deob- struents, pass into the blood by the veins or lymphatics, where they either modify its con- dition, or excite the extreme vessels when they are congested, thereby accelerating the circu- lation through them and the veins, and remov- ing the state that favours increased exhalation.— (a) Mercurial preparations are amongst the most common medicines employed as deobstruents. But they are not always applicable; for when the dropsy is connected with organic change in the substance of the liver, they should be given with circumspection. When the obstruction exists chiefly in the veno'is and lymphatic systems, or depends upon disease of the heart; or when [edicines recommended in. 620 DROPSY —Remarks on M the effusion is caused by increased action in the serous membranes; they are valuable medicines. The scrofulous diathesis and weak vital energy are not always satisfactory reasons against their use, although these states of system require a peculiar mode of exhibiting and combining them. In acute cases, calomel, with antimony or cam- phor and opium, is the preferable medicine. In this and similar states of preparation, it has been employed by Lvsons, Langguth, Hamilton, Becker, and others. Where active disease exists in the pleurae, pericardium, peritoneum, or sur- face of the liver, this is the best mode of exhibit- ing mercurials; but where there is much debility, this medicine should be given in small doses with soap, and guaiacum, as advised by Riepenhau- sen; or in the form of Plummer's pill, with soap and taraxacum. In an atonic or asthenic state of vital action, as well as in the scrofulous diathesis, small doses of blue pill, similarly com- bined; or of the sublimate, dissolved in the com- pound decoction of sarsaparilla, or tincture of cinchona, with diuretics; will be found both safe and beneficial medicines. Mercurials have been directed to be pushed to salivation by many authors; and in cases where the disease is con- nected with inflammatory action in the serous membranes, and when vascular depletion has been previously instituted and carried sufficiently far, the practice is beneficial. It is likewise applicable when there is evidence of inflammation of the surface of the liver, as indicated by pain, soreness, and tenderness of its region, &c. In the more chronic and asthenic states of disease, mercurials have been directed to be given with squills, by Fischer and other writers; and with tonics, by Wright. 64. (b) Iodine, variously combined, has proved, in several cases of dropsy in which I have em- ployed it, a most valuable deobstruent and diu- retic. It is not applicable to the cases arising from disease ofthe serous membranes, and heart; but when the effusion proceeds from obstruction in the liver, or in the spleen, or in the veins and ab- sorbents (§26, 27. 31.), it seems to me more to be depended upon than any other medicine. I have prescribed it in the form of tincture, hydriodate, idioi~utted solution of the hydriodate, and of ioduret of mercury, both internally and externally, according to the circumstances ofthe case; and have more frequently preferred the second and third of these preparations; but when the de- bility is great, the tincture is, perhaps, more to be depended upon than the others.—(c) The fixed alkalies and their sub-carbonates have had much repute in dropsies, and were very com- monly employed by Sydenham, Quarin, J. P. Frank, and most recent writers. Although generally used as diuretics, they act chiefly as deobstruents, particularly when combined with taraxacum, small doses of antimony, or of mer- cury. In cases of debility, they are extremely useful with the tonic or warm diuretic infusions or decoctions,— as the infusion of cinchona, of juniper berries or pine tops; and they may be also associated with the nitrate of potash and diuretic syirits or tinctures. Or they may be prescribed with myrrh, or guaiacum, or sulphur, or ammoniacum, or squills, or camboge, or the extract of black hellebore, according to the pecu- liarities of the case —(d) The sub-borate of soda is a very usefnl adjunct to other deobstruents, and to diuretics (see F. 57. 397.599.). I believe that its deobstruent action is greater than that of the alkaline carbonates.—(e) Ammoniacum has also been exhibited, chiefly on account of its deobstruent operation, and is indicated in the atonic states of the disease, and in the com- plications with organic change in the liver, spleen, or kidneys; and in cases of venous, ab- sorbent, or glandular congestion or obstruction. In these it may be conjoined with alkalies, ex- tract of taraxacum and squills (see F. 552. 893,894.). Fordyce gave it with antimony and nitre,— a form in which it may be safely pre- scribed in the acute and sub-acute cases, after vascular depletion and purgatives; and Richter, with the muriate of ammonia and squills.—(/) Sulphur, when judiciously associated with other deobstruents and aperients, or with diuretics, possesses no mean deobstruent properties, more particularly when given with cream of tartar, as Hufeland advises; or with this substance, the sambucus nigra, and the sub-borate of soda; or with the nitrate of potash, and squills; or with the balsams, as directed by Mondschein. 65. (g-) The external deobstruents consist of certain of the substances already noticed, kept constantly applied over the chest, or the loins, or hypochondria, in the form of plaster; or assi- duously rubbed into the same places, in the form of liniment or ointment. The Appendix will furnish, under these heads respectively, several preparations, consisting chiefly of ammoniacum (F. 109. 117. 891.), the preparations of iodine (F. 302. 768. 775.), of the terebinthinates ( F. 120. 296, 297.), of mercury ( F. 511. 761.), of camphor ( F. 115. 306. 758.), and of the sul- phurets (F. 309. 776.), with other substances; calculated to promote their operation, and allay internal pain and vascular irritation. Besides those now indicated, will be found arranged along with them, several preparations which may also be used according to circumstances.— (h) Fric- tions are of more benefit in dropsies, particularly in those which depend upon obstruction and atony of the vessels and tissues, than is usually imagined; and were commonly employed by Stoerck, Stoll, Rush,Wright, and others. They will be advantageously used with the lini- ments or ointments already noticed employed in weaker forms. Frictions with the weak mercurial ointment were advised by Broughton, Frank, and Knight; the addition of camphor to this liniment, as recommended by Lentin, or the linimentum hydrargyri reduced by the addition of olive oil, or of the linimentum saponis com- positum, will be found superior to the mercurial ointment alone. Frictions with olive oil were much confided in by Stoll,Oliver, Chamber- lain e, Lang e,Gard an e.Rush,andWmGHT, particularly in ascites, and anasarca; and are cer- tainly often beneficial in favouring a free tran- spiration from the surface, and do not merit the disuse into which they have fallen.—(i) The good effects of bandaging, not merely in anasarca, but also in ascites, were insisted on by Rush; and have lately been shown, in the latter form of the disease, by some French practitioners. 66. B. By purgative and hydragogue cathar- tics.—Purgatives are very generally applicable in dropsies—(a) on account either of their ecco- DROPSY — Remarks on Medicines for — Diuretics. 621 protic action, or of their deobstruent operation when uninterruptedly continued, or of their influ- ence in deriving from the seat of effusion, in draining the fluid parts of the blood from that circulating in the intestinal tube, in thereby les- sening excrementitious or serous plethora and favouring the absorption of the effused fluid. They constitute a most important part of the treatment of every form and state of the disease, according to the selection of them and the manner of combining them. Thus, calomel and antimo- nials, subsequently to bloodletting, are most ap- propriate to the inflammatory, the pulmonary, and cardiac complications; the hydragogue cathartics in ascites and anasarca; and the milder purg- atives associated with tonics and diuretics in the atonic or passive forms. The advantages to be derived from conjoining the saline purgatives with bitter infusions and with diuretics, even in the acute states of the disease, after the antiphlogistic treatment has been directed, should not be over- looked (§ 59.) The combination of purgatives and cathartics with tonics and diuretics, was adopted by Scribonius Largus, Forestus, Ried- lin, Sydenham, Thilf.nius, Bacher, Win- cler, Ritter, Grieve, and most recent wri- ters : the chief difference being as to the choice of substances, and the appropriation of them to the various states and forms of dropsy.—(b ) The de- obstruent effect of purgatives is most certainly ob- tained from moderate doses oi jalap with cream of tartar; or from the extract of black hellebore, with myrrh, ammoniacum, and soap; or from Plum- mer's pill, with camboge, soap, and taraxacum, given in moderate doses daily, and long persisted in. 67. (c) A hydragogue operation is produced chiefly by elaterium, croton oil, camboge, the inner bark of the common or dwarf elder, the rham- nus catharticus, hellebore, and the neutral salts. — a. Elaterium is often productive of benefit. It was much employed by Sydenham and Demi- ani, and is still very generally prescribed. It is given with soap or any tonic extract, in doses of half a grain every hour, until copious watery evacuations are procured. The following pills will be found the most certain in their operations :— No. 183. U Extr. Elaterii gr. vi. ; Potassae Sulphatis gr. x. : tere bene simul, dein contunde cum Pulv. Kadicis Zingiberis ►) j.; Saponis Duri gr. xvj., et forma in massam cum Olei Anisi IT} vj. vel q. s. Divide in Pilulis xviij., quarum capiat unain, duas, vel tres, omni hori. 68. p. Croton oil is one of the most certain hy- dragogue cathartics that can be employed. It may be given with soap and compound extract of colo- cynth ( F. 543.), or with the aloes and myrrh pill, in doses of about half a drop every two or three hours, until it operates copiously. Dr. Nim- mo and Dr. Goon prefer the alcoholic solution of this oil, but of that I have had no experience; I have found the mode in which I have directed it answer my expectations.— y. The extract of black hellebore has been much used in all drop- sical cases. This plant was very commonly employed by the ancients, and by Avicenna, Riedlin, Mondschein, Van Swieten, and Quarin. The extract as prepared ( F. 156), and combined, by Bacher, is, upon the whole, the best mode of exhibiting it. It should be fresh, and its effects carefully watched. If it produce restlessness and anxiety, it ought to be relinquished. The following is Bacher's recipe for the pills known by his name :— No. 184. R Extr. Hellebori Ni-ri, Myrrhae, aa § st.; Pulv. Cardui Benedict. 3 jss- Contunde secundum artem i.-i massam aequalem. Capiat gr. ij. ad vj. ter quaterve quotidie. 69. vj. and 5 j.); but two or three drachms twice or thrice in the day, and persisted in for several days, is preferable. It is apt to be nauseated by the patient; in which case the elec- tuary should be prepared with syrup of ginger, to which the oleum anisi, and a little tincture or powder of capsicum, may be added in addition to the other substances with which it may be requisite to conjoin it. In some cases, sulphur will be added to it with advantage; in others, guaiacum, ammoniacum, or squills; and in some the inspissated juice of the sambucus nigra, and extract of taraxacum. Its association with sul- phur was much confided in by Piderit; with borax, by Grant, Quarin, and most Continen- tal writers; with camboge, intimately triturated together, by Sala and others; with squills, by Bang ; and with jalap, by Demiani. Of other purgatives it is unnecessary to take any particular notice. The neutral salts, particularly the sul- phates, are often of great benefit, both as laxatives and as diuretics, when prescribed with other preparations possessed of the latter properties. The iris florentina, i. pseudacorus, i. vulgaris, i. versicolor, and i. fatidissima, have severally been employed as hydragogue cathartics in drop- sies, in the form ofthe expressed juice, or powder, infusion and decoction of the roots, and have received the commendations of Plater, Eller, DUVERNEY, andSpiNDLER. 71. C. By diuretics.— This class of medicines is, perhaps, more than any other, empirically pre- scribed in dropsies, owing chiefly to the imperfect state of our knowledge of, and iu some measure 55 622 DROPSY — Remarks on Medicines for — Diuretics. to want of attention to, the mode of their oper- ation. From researches into this subject, in which I was engaged during the years 1819, 1820-, and 1821,— part ofthe results" of which, particularly in respect of diuretics*, was published in the Medical and Physical Journal for July and Au- gust, 1821, p. 112 — 115.— it was there shown, that these substances act — i. Upon the digest- ive canal, and on the nerves of organic life, ex- citing or otherwise modifying, according to the nature of their impression, the functions of these viscera, and by sympathy the functions of those intimately related to them:—ii. By absorption, and by their action on the lymphatic, capillary, and venous systems, both during and subsequent- ! ly to their passage into the blood,— a. in exciting I the extreme vessels, or restoring their tone, and thereby promoting their circulating functions; 6. in exciting the absorbent system, and gradu- ally removing impediments in the way of the lymphatic and venous circulation, or in pro- ducing a deobstruent operation; c. in develop- ing constitutional power, increasing the vital cohesion of the soft solids, and enabling them to yield the requisite support to the capillaries and to the exhaling vessels and pores : — iii. By their action on the kidneys, and other secreting and excreting viscera, through the medium ofthe circulating fluid,— a. in directly stimulating the kidneys, by one or more of their constituents, during their presence in the blood and elimination with the urine, and in exciting them to excrete the watery parts of the blood; b. in thereby diminishing the quantity of the watery parts of the blood, and promoting the absorption of fluid from the cavities or tissues in which it super- abounds. It will be seen from the above, that substances which have had a diuretic action \ ascribed to them, operate — 1st, in a more or less indirect manner, whether their influence be mainly exerted upon the prima via, or upon the circulating systems and tissues by means of absorption; and, 2d, hi a direct manner, during their circulation through these organs, and elimi- nation from the blood by their agency. Con- formably with these views, I proceed to notice the use of this class of medicines in dropsies. 72. 1st. Indirect diuretics.—(a) Those which act chiefly upon the digestive canal. Under this head may be comprised most of the tonic and stimulating medicines already noticed, and which, | by increasing the organic nervous energy, and promoting the digestive and assimilating func- tions, also assist the circulating and eliminat- ing actions, particularly in the indirect manner already noticed.—(b) These effects are both ac- celerated and heightened by associating these medicines with substances which, being absorbed into the circulation, excite the extreme vessels, re- store their tone, and promote a healthy circulation through them. Of these last, some mention has been already made under the head of deobstruents * The former of these memoirs contained thf> first at- tempt that had been made to determine the precise way in which diuretics operate, and to arra.i^e tneir effects. In that article, as well as in the London Medical Repo- sitory for May, 1822. p 380, 381., will be found the ar- rangement of ihe action of diur> t cs given above, drawn iu a more precise and detailed manner than my limits will here allow me. I state this, because similar arrange- ment • have been put forth at much later periods than the last of these but without reference to the original sources dow referred to. (§ 63__66.). Mercurials, when used asdiuretics, operate chiefly in this manner, unless carried to the extent of injuring the constitutional powers, and of hazarding the production of their peculiar cachexia. Foxglove seems to act chiefly in this way, as well as in lowering the frequency and strength of the heart's action, thereby diminish- ing effusion, and determining the balance of action in favour of the absorbing vessels. Its effects are promoted by combining it with sub- stances which, being received into the circulation, act in a similar manner with it, or in one of the modes mentioned in the second order of the above classification (§71.); more particularly with the blue pill, or minute doses of the oxymuriate of mercury; with the nitric or nitro-muriatic acids, in broken-down constitutions, or where mercury has been already employed; with the spiritus aetheris nitrici, or liquor ammoniae acetatis; with the supertartrate of potash and borax; or with colchicum and the tinctura camphorae composita ( F. 195. 395. 400. 599. 627. 859.). The diu- retic operation of digitalis is most certain after depletions and alvine evacuations in the more acute states of dropsy, in the atonic forms of the disease, and in the complications with lesions of the heart and lungs. The preparations of this plant necessarily depend for their efficacy upon the period at which they are gathered, and the manner of drying them. As soon as the leaves or powder lose the green colour, they also lose their active properties. Digitalis was much re- commended by Schiemann, Withering, Darwin, I. Warren, Dick,0dier, Heusin- GER,and many others; and it still retains its rep- utation, particularly in hydrothorax. Ferriar prescribed it with cream of tartar; Langen- beck, with opium;andBEDDOEs,AcKESM an n, Knaus, and Lettsom, with calomel and opium. The addition of small doses of this last promotes its operation, and partially counteracts any unpleas- ant effect it may produce,— a fact which I have heard confirmed by the extensive and discrimi- nating experience of Sir II. Halford. The tinctura opii composita ( F. 729.) is perhaps the most eligible preparation for this purpose. The decoctum senega has also a diuretic effect, and evidently from its influence on the capillary cir- culation. It was used by Millman; but is applicable chiefly to the atonic states of the dis- ease. Oberteuffer conjoined it with cream of tartar, which is, I believe, the best way of giving it. Squills and ammoniacum (§ 78.*) seem to act, partly at least, in the present mode; but, of the former, more particular notice will be taken in the sequel. 73 (c) Diuretics which excite the absorbing vessels, and remove impediments to the lymphatic j and venous circulation, are manifestly few in num- ber. It is probable that several of those already noticed, aud usually termed deobstruents, operate partly in this manner; but we have no satisfac- tory proofs that they do so act, as to any of them, excepting the preparations of iodine, of which mention has already been made (§ 64.). These evidently excite the absorbing vessels, and produce a diuretic action in this way, particularly when given in full doses. The sub-carbonates of the alkalies, the pure fixed alkalies, ammoniacum, ' mercurials, &c. may probably also act partly in the same manner. DROPSY —Remarks on Mf 74. (d) There are various substances which exert a diuretic operation through the medium of the circulation, by developing constitutional power, increasing the vital cohesion of the soft solids, and thereby restrianing morbid exhalation or effusion. In this manner, all the tonic and astringent mineral salts may indirectly increase the secretion of urine, as well as the mineral and some of the vegetable acids. Lentin, Tissot, Wintringham, and others, prescribed the mine- ral acids; Rf.usner directed the sulphuric acid, with infusion of the bark or flowers of the sam- bucus nigra: and Bang, the tartaric acid with squills. Citric acid and lime juice have been found efficacious in the complication of dropsy with scurvy; and I have seen benefit derived from pyroligneous acid. Sulphate of iron, and sulphate of quinine with sulphuric acid, will also prove of service in the asthenic states of the dis- ease, by operating in this manner. But these are, upon the whole, inferior to the ferrum tar- tarizatum, which, whilst it increases the tonicity of the extreme vessels and soft solids, produces a very manifest diuretic action. 75. 2d. Direct diuretics.— Substances which stimulate the kidneys through the medium of the circulating fluid tire the only direct diuretics. But there are very few of them which act in this way solely; nearly all of them producing more or less effect upon the organic nervous system, on the vascular systems, and on the vital cohesion of the tissues, during their presence in the blood. It will be found that such of them as ex- cite the kidneys most remarkably are eliminated from the blood by these organs, and it may be therefore presumed that their influence is prin- cipally or specifically exerted upon them. It will be manifest, that substances which increase the proper function of the kidneys will produce the double effect above stated (§ iii. a. b.), of excreting the watery parts of the blood, of dimi- nishing excrementitious plethora, and thereby increasing the absorption of fluid from the situ- ations where it superabounds. I have long since shown (Lond. Med. and Phys. Journ. for July, 1821.) that certain diuretics, and these the most active, are conveyed into the circulation, and to the kidneys, unchanged; and Dr. Paris has con- tended that various other diuretics are decom- posed or digested, and operate by means of certain of their active constituents. This seems very probable as to some, but does not admit of proof in respect of many of them. That the balsams, juniper berries, and cubebs, excite the kidneys by means chiefly of their essential oil, is very evident; but that colchicum and squills are diuretic, owing to the separation of veratria and scillitina, is merely a matter of opinion. 76. (a) a. Oil of turpentine, and substances con- taining it, as the Canadian, the Chian, the Vene- tian, and the common turpentines, are the most energetic and direct diuretics that can be pre- scribed; and, in the endless forms of combining and exhibiting them, admit, in the hands of the practitioner who is acquainted with their proper- ties and effects, of very general application: as they excite the tonicity of the extreme vessels and soft solids, during their presence in the circulation ; stimulate the kidneys, in the asthenic states; lower inflammatory action, and prevent, the consecutive effusion, in the acute forms of the dicines for — Diuretics. 623 disease. The oil, the active principle, may be taken as prescribed in the Appendix (F. 149. 169. 681.), may be exhibited in clysters, and employed externally in the form of liniment or epithem. Its smell may be covered by the caje- put or lemon oils, which also are direct diuretics; and the unpleasant eructations it occasions, in great measure prevented by giving it with mag- nesia, or by taking this substance immediately after it. In the asthenic states of dropsy, Mond- schein and Roland combined it with sulphur, in the form of balsamum sulphuris (F. 22.). The former of these writers also recommended the infusion of pine tops (F. 51.), which is an excellent diuretic vehicle for the saline sub- stances and spirituous tinctures belonging to this class of remedies (F. 827.).— p. The various balsams (F. 485— 487. 570.) are especially indi- cated in the more passive states of dropsy, and when the kidneys seem to be diseased. The Peru- vian balsam was much praised by D e Haen; but copaiba is equally efficacious. These, as well as the terebinthinates, may be given in the form of pill with magnesia, or with the alkalies. — y. The preparations of juniper berries also act directly upon the kidneys, by means of their essential oil. They are most appropriate in the sub-acute and asthenic cases, and are excellent adjuncts to other diuretics (F. 194.). The infu- sion (F. 235, 236.) is a suitable vehicle for various substances appertaining to this class (F. 397. 399.). Riverius prescribed it with small doses of sul- phuric acid; Bang, with cinchona; and Perci- val, with camphor.— o. Cajeput oil, oil of ani- seed, and others of the essential oils, possess diuretic properties, and may be used both internally and externally, as adjuvants of other substances be- longing to this class of medicines, especially in the more asthenic states of the disease. The oil of aniseed is very serviceable in effusion con- nected with asthma, bronchitis, or lesions of the lungs, and with affections of the heart; and is a useful adjunct to colchicum, digitalis, cam- phor, &c. 77. (b) The alkalies and their salts are diuretic in small or moderate doses, and are appropriate to most cases of the disease. Liquor potassa has been already noticed as serviceable in con- junction with other deobstruents and diuretics (§ 64.). It evidently neutralises the acid in the stomach, and is absorbed into the circulation. The sub-carbonates and carbonates of both potash and soda are more generally useful, especially in the complication with lesions of the liver, kidneys, and uterus, and when judiciously combined. They are also absorbed, and are decomposed by the acid (the muriatic, as shown by Dr. Prout) of the stomach. But as the quantity of this acid which the stomach contains at any time is but small, the change can be effected only on a por- tion of the salt, if it be given in full doses. A similar change is most probably produced upon some ofthe vegetable acid salts in the stomach by the same agent, as Dr. Paris has contended. The citrates or tartrates are useful and pleasant. They may be taken in bitter or diuretic infusions, whilst the fixed air is being disengaged by the action of the acid on the bicarbonates. The most certain, however, is the cream of tartar, in doses that act not energetically on the bowels. When pre- scribed in order to obtain its purgative effect 624 DROPSY — Remarks on Medicines for—Diuretics. (§ 70.), it frequently also excites the kidneys; and, with borax, it is sufficiently soluble to be given in the form of draught or mixture, with diuretic infusions. It is also advantageously conjoined with the ferrum tartarizatum and other tonics in the asthenic states of the disease; and is most serviceable in ascites and anasarca. For- mulae 57. 397. 588. 590. 599. 628. are the best modes of exhibiting it as a diuretic. Acetate of potassa and acetate of ammonia may also be ex- hibited with tonic or bitter infusions (F. 196. 386.), and with either the decoction, spirit, or infusion of the various diuretics about to be no- ticed (F. 194. 358. 395. 400.). The decoction and the extract of taraxacum are excellent ad- juvants of all the foregoing salts, as well as of the carbonates. They have been much praised by Bonet, Bang, and J. P. Frank, for their de- obstruent and diuretic operation (F. 390—392.). Nitrate of potash has already been noticed among antiphlogistic remedies (§ 55.). It is readily absorbed into the circulation ; and during its pre- sence in the blood and elimination by the kidneys, it excites the capillary vessels, and stimulates these organs. It is indicated in all the acute states of the disease; and in these, after de- pletions, as well as in the atonic forms, it may be given in tonic infusions and decoctions, with diuretic tinctures or spirits (F. 399. 401. 406. 588. 591. 599.). All the neutral salts, par- ticularly the sulphates, and the super-sulphate of potash, are absorbed, and excite the kidneys and extreme vessels, when taken in small doses, or much diluted. They are indicated chiefly in the acute or sub-acute varieties of dropsy, and in their complication with organic change in the liver. They admit of the same forms of ex- hibition as those more particularly mentioned, and are assisted in their operation by the same adjuncts. 78. (c) The action of the foregoing on the kid- neys is well ascertained; but there are several other substances which are as energetic as they, but whose mode of operation is not so well under- stood. That the diuretics now about to be no- ticed excite the kidneys by means either of one or more of their constituent principles, seems very probable; but they also act in a similar manner upon the tissues to which they are immediately applied; and, when taken in small or moderate doses, so as to be absorbed into the circulation, they manifestly stimulate the capillary vessels, or impart more or less tone to them. Hence they are most beneficial in the atonic forms of the disease; or in the sthenic and plethoric states, after evacuations. Of this class of diuretics, squill is the most generally used. Fr i z e , Sto l l , and Zeviani, advise it to be prescribed with cau- tion. It is commonly given with calomel and blue pill, in doses of a grain, gradually increased to five or six; or with the neutral salts, in the form of vinegar, tincture, or oxymel. Cullen pre- scribed it with the oxymuriate of mercury; Lang- i haus, Home, Lange, and Broughton, with nitre, rhubarb, cream of tartar, &c; Tissot, with camphor; Willich, with tartar emetic; Bfr- J trand, with the jEthiops mineral; and Knee el and Leake, with opium. When it irritates the stomach or bowels, in conjunction with mer- i curials or saline substances, the addition of opium j is requisite, if the propriety of continuing the' I combination be still manifest; but, under such cir- cumstances, it is seldom productive of benefit; and, in cases where vascular plethora or sthenic action is present, it is more injurious than beneficial. The preparations of it in the British Pharma- copoeias are the best modes of exhibiting it; and these may be combined as directed in the Ap- pendix (F. 196. 399. 533. 552. 627. 781. 893.). This substance is indicated principally in the atonic states of effusion, when the urine is high-co- loured and scanty (Blackall), and it acts more energetically upon the extreme vessels than on the kidneys. 79. Genista, or spartium scoparium, the com- mon broom, in the form of decoction, has been prescribed by most writers on dropsies (F. 95.) ; as well as the sarsaparilla, various species of the similax evidently possessing diuretic properties. Gratiola officinalis, or hedge hyssop, in the form of inspissated juice or decoction, was recom- mended by Duverney andSTOERCK in dropsy consequent upon scarlatina, both as a purge and as a diuretic, in small doses. The pyrola umbeU lata has been employed by Ru dolph and Somfr- ville. The former combined it with tartar emet- ic and opium. Dr. Somerville, Dr. Beatty, and Dr. Bigelow have adduced strong evidence in favour of its diuretic operation. The decoction is the most active form of exhibiting it. It seems most efficacious in the hepatic complications of dropsy. In addition to these, the infusions of the ballota lanata and of the b. suaveolens have been prescribed by Rehmann ; the decoction of thepetroselinum, or parsley, by Richter; the inspissated juice of the rhaphanus rhaphanistrum, by Gruling and others; the expressed juice or infusion of charefolium, or musk chervil,, with nitre; the chenopodium anthelminticum and c. ambrosioides, by Lentin; the dehorium verru- carium and chondrilia juncea (species of succory), by Spindler. Several species of saponaria, the angelica archangelica, the levisticum, or lovage, the sium berula, sassafras, sweet fennel, asparagus, and various other plants, have been recommended by authors, in the form either of infusion, decoc- tion, or ofthe expressed juice. 80. Colchicum was much used by Stoerck, Boehmer, Erhmann, De Meza, and Ober- teuffer, asa diuretic. It possesses much of this property, when it does not irritate the sto- mach or bowels. Hautesifrk justly considers it inferior to squills. In the acute states of dropsy, it is best given with mercurials in pow- der; but, in asthenic cases, it is most advantage- ously conjoined with the warmer diuretics, with tonic infusions, or with preparations containing camphor or ammonia (see F. 194. 395.), or with large doses of the alkaline sub-carbonates, par ticularly in the gouty or rheumatic diathesis. Stoerck combined it with the infusion of rhu- barb; andOBF.RTEUFFER, with cream of tartar, juniper, and guaiacum. The diuretic action of rhubarb is deserving of notice. When given either in small doses, or in infusion as a vehicle for other substances of this nature, — as the saline diuretics and the preparations of squills, of juni- per, or of colchicum,— it is a useful medicine in dropsies. It was employed in this way by Wk rl- hof, Fordyce, Bang, and Rush. Thediosma crcnata also acts upon the kidneys. Its infu- sion may be used in similar cases and states of DROPSY — Remarks on Medicines recommended in. 625 combination to those in which rhubarb is appro- priate (see F. 231. 396.). The marchantia hemi- spherica, or liverwort, has been recently em- ployed with much benefit by Dr. Shortt, in cases where other remedies had been employed without advantage. He has, however, found but little service from its internal use, and has em- ployed it chiefly externally as a poultice. For this purpose it is first boiled, afterwards beat into a pulp, and mixed with as much linseed meal as will bring it to the consistence of a poultice, which is spread upon flannel, and applied warm over the seat of the effusion, repeating the poultice every twelve hours, until the accumulation of water is removed. It produces " copious perspir- ation, and at the same time acts powerfully on the kidneys." The sinking sensation it sometimes occasions is relieved by the spiritus aetheris nitrici. The effects of this application are stated to be increased by allowing the patient warm and nourishing diluents, and beef tea, &c. Dr. Shortt believes that this application will be found to succeed in many cases where the kid- neys are affected. The bark of the root of ci- chorea racemosa anquifolia has been lately em- ployed by M. Lf.hasso.n. This bark furnishes a crystallisable principle, of a bitter and astrin- gent taste, soluble in water and alcohol, in which the virtues of the plant reside. A decoction of two drachms of the bark in eight ounces of water is divided into two doses, which are taken with an interval of two hours. This generally affects the kidneys, and the action continues for some days. As soon as its action begins to diminish, the same doses are repeated. It is suitable only to the asthenic states of the disease. 81. Cantharides have been recommended in dropsies, on account of their diuretic action, by Hippocrates, Galen, Dioscoridf.s, and others among the ancients; and by Brisbane, Fa rr, and several modern writers. Hoffmann, Werlhoff, and Hufeland, gave them with cream of tartar, the tartaric acid, or nitrate of pot- ash, and with camphor; and Tulpius in the form of tincture with spiritus aetheris nitrici, cardamoms, &c. They should be exhibited with great cau- tion, and only in the most asthenic forms of the disease. Dr. Groenevelt, a licentiate of the college of physicians, was committed to Newgate in 1693, by the president and censors, on the plea of mala praxis for prescribing them in diseases of the urinary organs, although numerous author- ities in support of the practice could have been adduced. Cantharides act upon the kidneys, and upon the capillary system, chiefly from the ab- sorption of their active principle, which has been termed canthariden. 82. The tethers also act upon the kidneys, es- pecially the spiritus atheris nitrici, and spiritus atheris sulphurici. They are useful chiefly as adjuvants of other diuretics. The sweet spirit of nitre is, however, an active diuretic when judici- ously combined, or when given while the patient can take excercise in the open air (see F. 169. 195, 196. 397.). It may be remarked generally respecting the use of diuretics, that the addition of small doses of opium, or of the tinctura opii comp. (F. 728.) as advised by Hufeland and Paris; and of out-door exercise, as directed by Tissot; will much augment their operation. H-inv ofthe Continental writers ad\i»e them to 53 be taken in malt liquors — a vehicle which cer- tainly promotes their action, and is not inappro- priate in the asthenic forms of the disease. It is in these forms principally that Dr. Rush con- ceived that any advantage was derived from this class of medicines; and Deckers, Prize, Mursinna, and MAGENNis,seem to have been of nearly the same opinion, they having recom- mended them to be given with tonics. 83. D. Emetics have been employed by several authors, particularly by Sydenham, Lilue, J. P. Frank, and Percival, chiefly after other medicines had failed; and some advantage has been said to have accrued from them. Squills are the emetic most commonly employed, which probably are partially absorbed, and act also as a diuretic. Several writers have mentioned in- stances of the disappearance of dropsy after spontaneous vomiting; and have looked upon this circumstance as an indication for exhibiting emetics. They are scarcely ever used in modern practice, and probably the cases are few in which they are indicated. I have seen, however, in- stances wherein obstinate vomiting supervened apparently upon the medicines which had been exhibited as diuretics, particularly digitalis, squills, and colchicum; but the good effect that appeared in these cases was attributable to the preceding course of medicine, and to the accumulated effects of these substances upon the system. 84. E. Diaphoretics and sudorifics have been recommended by most writers. But in the ma- jority of cases, particularly in the acute and ple- thoric, there is great difficulty in producing perspir- ation; the means which are employed, unless they be of a contra-stimulant or relaxing nature, tending rather to excite the vascular system, and to in- crease the morbid exhalation, than to relax the surface, and produce diaphoresis. Tartarised an- timony, Dover's powder, and spirittis atheris ni- trici, are, perhaps, the best sudorifics that can be employed; but the former should be given, in the acute cases, so as to occasion some degree of nausea; and the last named, in asthenic cases. Dover's powder was much confided in by Mu d g e , and guaiacum by Chamberlaine andBRucK- m ann. As to the propriety of resorting to warm bathing, in order to induce perspiration, much difference of opinion has existed. Tepid baths were recommended by Stoll and Frank, in the acute states ofthe disease, and vapour baths by Darbey and others. 85. F. Mineral waters, if judiciously directed and brought in aid of medicine, are often produc- tive of much benefit. Zacutus Lusitanus re- commends the internal use of sea water; and there can be no doubt that it will prove beneficial if persisted in, particularly in the sub-acute and atonic states of the disease. In the more asthenic forms of dropsy, the Bath waters, the mineral waters of Carlsbad, Ems, Marienbad, and Vichy, and those of Seltzer, are often serviceable. In cases depending chiefly upon obstruction, and where an aperient action is desired, the waters of Harrogate,Moffat,andLeamington*may be tried. * Dr. Loudon, of Leamington, favoured the author with the results uf an ext naive series of experiments made to ascurt in the composition of these waters. There are eleven springs of mineral water, seven of which re purely saline, three sulphureous, and one chalybeate. The saline contains -098 cubic inches of oxygen, -763 of azote, 3- 15b' of carbonic acid, 34-435 grains of sulphate of soda, 626 DROPSY —Remarks on Medicines recommended in. 86. G. The combination of two or more of the I plans now mentioned is often necessary. But this must depend entirely upon the nature of the case in respect of vital energy, and of visceral complication. Certain, however, of the above classes of measures are incompatible one with the other ; as purgatives with diaphoretics, and ca- thartics with diuretics. But a moderate purgative action will often not materially prevent the oper- ation of medicines on either the skin or kidneys; and some purgatives will even act sensibly upon both the bowels and urinary organs, particularly cream of tartar. Deobstruents, emetics, and ex- ternal applications, often aid the operation of both diaphoretics and diuretics. Various substances, especially those of vegetable origin, are even more diuretic when applied in the form of poultice, or fomentation, or liniment, to the cutaneous surface, than when taken into the stomach, probably owing to the alteration or digestion they undergo in the alimentary canal, by which they partially lose their activity. Several of the older writers insist- ed much upon the external use of medicines in this disease, evidently from having witnessed in- stances of the success of the practice. 87. Diet.—In respect of diet, little need be added. It should entirely depend upon the form of the disease — be spare and cooling in the acute cases, and light and nourishing in the chronic or asthenic ; and directed with reference to the vis- ceral complication. The patient should not be restricted from drink. Under the head " Potus," in the Appendix, will be found formulae for sev- eral beverages, which may be reduced, modified, or rendered agreeable, as circumstances may re- quire such changes. Weak Hollands or gin-punch, or cyder, perry, or soda water, may also be al- lowed, according to the habits of the patient. Spruce beer is, perhaps, the best. Bibliog. and Refer.— Hippocrates, Aphorism. 3—7.; Iltpl vovouw, i. ii.; et Opera, passim. — Aretaus, Chro- nic. 1. ii. ch. 1.— Galen, Loc. Affect. 1. v. 7. ; et Symp. Caus. 1. iii. 8.—Calius Aurelianus, Morb. Chron. 1. iii. cap. 8.—Scribonius Largus, De Comp. Medicament, fol. Paris, 1528, sect. 126. editio princeps.—Mesui, Sen. sect. i. cap. 13.—Avicenna, Canon, iii. fen. xiv. tr. iv. cap. iv.----- Fernelius Consil. xxxii. et seq. — Forestus, 1. xix. obs. 14 — 39. — Plater, Observ. 1. iii. p. 655. — Ballonius. Op. vol. i. 192. — Bartholin, Epist. p. 290., iii. p. 132. 327.— Schenck, 1. iii. sect. ii. obs. 112. et seq. — Willis, Pharnia- cop. Ration, par. ii. sect. ii. 3. 5. — Horstius, Opera, ii. p. 199. 271. — Actuarius, 1. iv. cap. 7. —Bourgeois, Ergo praecavendo Hydr. Vena-sectio. Paris, 16-8. — Magninus, De Tabacco. Ticin. 4to. 1648. — Perreau, Ergo Hydropi Elaterium. Paris, 1658. — Riverius, Praxis, p. 67. — Sy- denham, Opera, p. 199. 618. — Zacutus Lusitanus, Prax. Hist. 1. viii. observ. 53. — Lower, in Philosoph. Trans. No. 29. —J. Groenevelt, De Tuto Cantharidum in Med. Usu interno, 12mo. Lond. 1698. — Bonet, Sepulchret. 1. iii. sect. 21. et sect. 37.; et Med. Sept. 7 '5.; et Polyalthes; de Hydrope, iv. cap. 47. — Morton, Phthisiologia, f. i. cap. 10. p. 21. — Glisson, De Rach. 14. — M. Lister, Exercita- tiones de Hydr. Lond. 1697. — Riedlin, Lin. Med. 1700, p. 367. — Eyselius, De Ebrietate assidua Hyd. Causa. Erf. 1701. —Piso, Observat. No. 118. — Neander, Tabacologia, p. 151,—Stahl, Ue Hydrope. Halae, 17 II. — Slodne, Voyage to Jamaica and Madeira. Lond. fol. 17 7. — J. W. Mondschein, Die Wassersucht nach ihrem Ursprung, &c. Hamb. 8vo. 1712. — Fuller, Medicina Gymnastica, 8vo. Lond. 1711.—Duverney, in Mem. of Acad, of Scien. Paris, 14-534 of chloride of sodium, 17-570 of chloride of calcium, and 26-050 grains of chloride of magnesium, in the Imperial pint. The sulphureous wells, besides these ingredients, contain 3-620 inches of sulphuretted hydrogen. The chal- ybeate differs in no way from the saline, but in containing 8-5H0 grains of bisilicate of iron. They are all, therefore, purgative waters. The dose is a pint daily or every other day; and a course of six weeks is generally directed. Small portions of iodine and brome, also, have been discovered by Professor Daubeny in these waters. 1701, 181., et 1703, 181. — Baglivi, De Pr. Morb. 1. .. c. 8 -Littre, Mem. Acad. Scien. Paris, 1703, p. 111.; et Ibid 1707, p. i,67.; et An Hydrope Vena*, ctio ? Pans, 1714.— Erastls, Disput. vol. iv. p. 206.- Blankard, Collect. Med. Phvs. cent. v. n. 25.—Schroeder, Pharmacopeia, 1. iv. p. 64. - hi. Tiling, Nephrologia. Fr. 1719, 12. — *>'«;, Hepar in Hyd. Sa-pius insons, kc. Witteb. 1720. — Bianchi, Hist. Hepatis, par. ii. cap. 5. — Blackmore, On the Dropsy, kc. Lond. 8vo. 1727.— Morgagni, De Caus. Morb. epist. xxiv. art. 18., epist. xxxviii.—F. Hoffmann, Opera, Supp. ii. 2. — Helwig, Observat. 83.—Dover's Legacy, p. 32.—Schulze, De Venassectione in Hydropicis. Halae, 1736. — Gilchrist, Use of Sea Voyages, &c. p. 88.— Gruling, cent. i. obs. 85., cent. ii. obs. 56., cent. iv. obs. 73. — Oliver, Philos. Trans- act, vol. xlix. par. i. p. 46. —Laurence, De Hydrope, 12mo. Lond. 1756. — Ritter, De Purgantibu; Validis et Opio in Hydr. Vien. 1754.—Tissot, De Variolis, Apoplexia, et Hy- drope in Sandifort's Thesaurus, &c. vol. ii. — A. Stoerck, De Rad. Colchici Autum. 8vo. Viudob. 1763. ; et Ann. Med. i. p. 82. — Buchner, De Diversa Hydr. Medendi Methodo. Halae, 1766.—Juncker, De Aq. Hydr. Vacuatione prudenti, kc. Hals, 1768.— Quarin, Anim'adversiones, cap. 8. p. 191. et passim. — D. Monro, Essay on the Dropsy and its differ- ent Species. Lond. 1765. — De Haen, Rat. Med. iv. p. 77. et seq., v. p. 38. et seq., vi. p. 61. et seq. — Mackenzie, Med. Observ. and Inquir. vol. ii. p. 287. —Baker, Trans, of Coll. of Phys. vol. ii. p. 235. —Stoerck, Ann. Med. i. p. 121., ii. p. 177. — Lentin, Memorah. 33. Beobach. 97. 100., kc. Be- obach. der Epid. p. 93., et Beytrage, &c. p. 115. — Vallis- neri, Opp. vol. iii. p. 269. — D. Lysons, Essays on Fevers, Dropsies, and on the Effects of Calomel, kc. 8vo. Bath, 1772. — Ribe, Schwed. Abi.andl. b. xiv. p. 47. — Bergius, in Ibid. b. xxiii. p. 121. — Fouquet, Recueil, kc. p. 80. et 293.—Gardane, Gazette de Sante, p. 254—279.—Brockles- by, Econ. and Med. Observ. p. 278.— Odier, Man. de Med. Prat. p. 214. —R. Wilkes, Es ay on the Dropsy, 8vo. Lond. 1781.—Fun Swieten, ad § 1240.—Hautesierck, Recueil, vol. ii. p. 308. 360.—Piderit, Pract. Annalen, st. i. p. 91.— Werlhof, Opera, vol. iii. p. 699. — Lange, Miscell. Verit. vol. i. p. 67. — Ehrmann, De Colchico Autumnale. Basil, 1772. — Backer, Exposit. des diff. Moyens usite9 dans le Traitem. des Hydr. Pans, 1771. —Fuller, Pharmacop. Ex- temp, p. 212. — Lieutaud, Hist. Anat. 1. ■., et 1. ii. var.— Bach r, Recherches sur les Maladies Chroninues, particul. sur les Hyd. kc. 8vo. Paris, 1776.— Bang, in Act. Reg. Soc. Haun. vol. i. p. 257., et vol. ii. p. 64.— Burrowes, in T ans. of Irish Acad. vol. iv. No. 83. — Frank, in Comment. Soc. Scien. Goet. vol. vii. p. 64. — De Meza, in Collect. Soc. Med. Hafn. vol. i. No. 7.; et Act. Reg. Soc. Haun. ii. p. 266.—Lillie, in Ibid. vol. i. p. 294.—Aaskow, in Ihid. vol. i. — Hewson, Experimental Inquiries, &c. v. ; Edin. Med. Comm. vol. iii. p. 42.—Fordyce, Fragmenta Chirurg. et Medica, 8vo. Lond. 1784. — Portal, Anat. Medicale, v 1. iv. p. 118.—Bader, Observ. 44.— Home, Clinical Exp. Observ. and Inq. 8vo. Edin. 1781.—F. Milman, De Natura Hvdro- pis ejusque Curatione. Lond. 1779, 8vo. — Latham, Philos. Trans. 1779. 54.— Withering, On Foxglove aud its Medical Uses, with Remarks on Dropsies, kc. 8vo. Birmingh. 1785.— Berends, De Remed. Antihydr. maxima celebrat. Laude et Auctoritate. Fran. 1804.—Boehmer, De Secura Hydr. Cu- randi Ratione. Halae, 1779. — Greulich, Cur. Hydr. Nova Methodus, 8vo. Fran. 1781. — Murray, Hydr. Curt. &c. Ups. 1785. — Garden, in Duncan's Med. Comment, vol. iii. p. 330.— Musgrave, in Ibid. vol. iv. p. 337., vol. v. p. 194. 415.— Ring, in Ibid. vol. viii. p. 83.— Grievv, in Ibid, vol. ix. p. 286. — Darbey, in Ibid. vol. ix. p. 315. — Broughton, in Ibid. vol. ix. p. 368., et vol. xix. p. 79. — Dick, in Ibid. vol. x. p. 207.— Bennet, in Ibid. vol. xii. p. 15.— T. Ham- ilton, in Ibid. vol. xii. p. 370. (Advises cyder.)—Lawson, in Ibid. vol. xiii. p. 299.— Garnet, in Ibid. vol. xvi. p. 271.— Bishopric, in Ibid. vol. xviii. p. 138. —Elliot, in Ibid. vol. xvii. p. 46.—Gordon, in Ibid. vol. xviii. p. 75.— Langguth, De Mercurio dulci potentissimo Hydr. domitore. Vit. 1780. — Richter, Med. und Chirurg. Bemerkung. p. 278.—Ciotti, in Gion:ale di Medicina, 1782. — Colin, De Lactuca Virosa, 8vo. Vien. 1780.; and Lond. Med. Journ. vol. i. p. 263.— Wright, Lond. Med. Journ. vol. i. p. 266.-; et Ibid. vol. x. p. 149. — Camper, Mem. Soc. Roy. de Med. t. vii. 46.— Mason, Med. Observ. and Inquir. vul. vi. p. 19. — E. Dar- win, Med. Trans, of Coll. of Phys. vol. iii. p. 255. 448. — Mudge, in Ibid. vol. ii.—F. Knight, in Ibid. vol. iii. p. 368. — G. Pearson, in Ibid. vol. iii. p. 316. — Stoll, Rat. Med. vol. i. p. 295., vol. ii. p. 158. 378., vol. iii. p. 5. 132. 277. 300., vol. vii. p. 340.; et Praeleot. i. 52.—Th. Fowler, Med. Rep. of the Effects of Tobacco in the Cure of Dropsies, &c. 8vo. Lond. 1785.—C. Darwin, Lond. Med. Journ. vol. vi. p. 55.—J. Warren, in Ibid. vol. vi. p. 145.— Cook, in Ibid. vol. vii. p. 54.—Hall, in Ibid. vol. vii. p. 157.—Stark, Observ. Clinic. — Schwenkers, Ueber Wassersucht, von Schmalz, 8vo. Dresd. 1787.—Mezler, Von der Wassersucht, 8v'o. Ulm. 1787.—Rush, Med. Observ. and Inq. vol. ii. p. 161. —Brisbane, Select Cases, &c. p. 13. — Sim, in Phila. Med. Museum, vol. i. p. 316.— J. P. Frank, De Curand. Horn. DROPSY OF THE ABDOMEN —Causes of. 627 Morb. 1. iii. p. 75.; et 1. vi. par. i. p. 322.; ct Act. Insti- l tut. Clinic. Vilnen. An. ii. p. 42.—Demiani, in Baldinger's Syllog. Op. vol. iv. — Willich, in Baldinger's N. Mag. b. | viii. p. 249. — Rudolph, in Ibid. b. viii. p. 235. — Letisom, in Mem. of Med. of Lond. vol. i., et vol. ii. p. 145. — Farr, in Ibid. vol. ii. p. 132.— Winship, in Ibid. vol. ii. p. 368.— Chamberlaine, in Ibid. vol. iii. p. 561. 571.— Wright, in Ibid. vol. iii. i). 563. — Walke-, in Ibid. vol. v. p. 449. — Briickmann, in Baldinger's N. Magaz. b. vii. p. 20. —Bal- dinger, in Journ. xx. p. 38. — W. Luxmore, Address to Hydropic Patients. Lond. 1796.—Osiander, Beobacht. 114. — Grapengiesser, De Hyd. Plethorico, 8vo. Goet. 1795. — Guthrie in Duncan's Ann. of Med for 1799, p. 482. — Friz'e, Annalen, b. i. p. 92. — Ferriar, Med. Hist. vol. ii. No. 3. ; and on the Med. Properties of the Digitalis Purp. Munich. 1799.—Percival, Essays, Sic. vol. i. p. 233., vol. ii. p. 156. — Horn, BeitrSge zur Med. Klinik. b. ii. p. 211. -- Boehmer, De Hyd. ejus Causis et Curat. Viteb. 1799. — Bo- eclemann, De Hyd. et Vasorum Lymphat. Irritabilitate. Erl. 1800.—Thomann, Annalen, ad 1800, p. 357.—Soemmerring, De Morbis Vas. Absorbentium, p. 125.— E- Ploucquet, Sis- tens Hydr. cum Scarlatina coincid. Exempla. Tub. 1801.— Arnemann, Annalen des Clin. Instit. heft. i. — Doemling, in Horn's Archiv. b. iii. p. 438.—Breschet, Sur les Hydrop- isies Actives, 4to. Paris, 1812, rev. in Corvisart's Journ. de Med. l*ov. 1812, p. 300. — W. Hamilton, On the Digitalis Purp. in Dropsy, Consumption, &c. 8vo. Lond. 1807. — Schmidtmann, in Hufeland's Journ. d. Pr. Arzneyk. b. iii. p. 522.—Miiller, in Ibid. vol. iv. p. VIZ.—Schceffer, in Ibid. b. vi. p. 245.— Hufeland, in Ibid. b. iv. p. 600., et b. v. p. 650.—Obertcuffer, in Ibid. b. v. p. 615— Selig, in Ibid. b. iii. p. 291. — Fischer, in Ibid. b. iv. p. 637. — Conradi, in Hufeland's Journ. d. Pr. Heilk. b. xxi. st. 1. p. 37.— Beck- er, in Ibid. b. xxi. st. 1. p. 22.— Hufeland, in Ibid. b. xxii. st. 4. p. 25. — Beddoes, in Med. Facts and Observat. vol. v. n. 2. — Shuttleworth, On Dropsy, tc. 8vo. Liverp. 1808. ; an I Edin. Med. Journ. vol. v. p. 217.— Erdmann, De Hy- dropis Natura, et Curatione. Viteb. 1808. — Zeviani, in Mem. della Societa Italian,!, vol. ix. n. 8. — Gaultier de Claubry, in Journ. Gen. de Med. t. xvi. p. 6___D. A. G. Richter, Die Specielle Therapie, b. iii. p. 8.—Buteman, art. Dropsy, in Rees's Cyclopaedia.—Briickmann, in Horn's Archiv. July, 1811, p. m.—Heusinger, in Ibid. Sept. 1811, p. 351.— Langenbeck, in Goet. Anz. 1812, p. 191.— Horn, in Archiv. fur Pract. Med. b. v. p. 119. 362. — Loebel, in Horn's Archiv. Jul. 1820, p. 178.—Fauchier, in Bulletin de la Facult. de Med. a Paris, No. 3. 1812.— Welts, Trans, of Soc. for Imp. of Med. and Chirurg. Knowledge, vol. iii. p. 194. — Blackall, On Dropsies, 8vo. Lond. 1813, rev. in Ed- in. Med. Journ. vol. ix. p. 334.—Abercrombie, in Edin. Med. Journ. vol. xiv. p. 163.—Hunter, in Ibid. vol. xiv. p. 6lfi. —Marcet, in Trans, of Med.-Chirurg. Soc. vol. ii. p. 342.—Somerville, in Ibid. vol. v. p. 340.—Bostock, in Ibid. vol. x. p. 77.—Dempster, in Edin. Med. Journ. vol. xvi. p. 64.—Lewins, in Ibid. vol. xvi. p. 359.— Graham, in Ibid. vol. xviii. p. 225.—R. Christison, in Ibid. No. lOl.p. 264.— J. C. Gregory, in Ibid. No. 109. et 110. p. 54.— T. Shortt, in Ibid. No. 114. p. 129. — Rehmun, in Nouv. Journ. de M6d. t. v. p. 114___Tucheron, Recherches Anat. Patholo- giques, t. iii. p. 190. — Percival, in Dublin Hosp. Rep. vol, I. p. 293.—F. G. Geromini, Sulla Generi e Cura dell' Idrope, 8vo. Crem. 1816. — Stoker, Pathol. Observ. on Dropsy. Dub. 1823.—Crampf on, in Trans, of Coll. of Phys. of Dublin, vol. ii. p. 150. — Laennec, Archives Ginir. de Mid. t. vi. p. 619. (Obliteration of vena cava.) — Portal, Sur la Nature et le Traitement de l'Hydropisie, 2 vols. Par. 1824. — E. Blasius, in Journ. des Progre's des Scien. Med- icates, t. xii. p. 102.—Itard, in Diet, des Scien. Medicates, t. xxii. p. 375.—P. Rayer, in Diet, de Med. t. xi. p. 420.— J. Boulllaud, Diet, de Med. et Chirurg. Prat. t. x. p. 174. — Lemasson, in Journ. Hebdom. de Med. Oct. 1831.— Mondat, Des Hydropisies et de leur Cure, 8vo. Paris, 1818. — G. Gregory, A Lecture on Dropsy, 8vo. Lond. 1819.— J. Ayre, On the Nat. and Treatment of several Forms of Dropsy, 8vo. London, 1825.—R. Venables, Clinic. Rep. on Dropsies, 8vo. Lond. 1824. — M. Good, Study of Med. vol. v. p. 367. — Bright, Medical Reports, kc. vol. i. p. 78. 4to. Lond. 1827. — Hodgkin, in Med. Gazette, Jan. 1832. III. Dropsy oftheAbdomen.-Svn.''.7(i«iti;? (from aay.bg, a leather bottle); Ascites, Auct. var; Hydroccelia, Hydrops Abdominis, Hy- dro-abdomen, Dropsy ofthe Peritoneal Cavity; Die Bauchwassersucht, Germ.; Ascite, Hydro- pisie Asdte, Fr.; Idropisia Asdte, Ital. 88. D e f i n . Heavy, tense, and fluctuating swel- ling of the whole abdomen, arising from a collect- ion of watery fluid in the cavity of the peritoneum. 89. i. Causes, &c. (a) The great extent ofthe peritoneum, the number and importance of the viscera with which it is connected, and of the absorbent glands it encloses, the numerous sources of disorder to which these organs are exposed, the great number and weakness of the veins which transmit their blood to the portal vessels, and the absence of valves from them, in some measure account for the frequent accumulation of fluid in this cavity. Ascites may arise from any of the causes enumerated above (§ 8, 9.), and at any age. Camper, Lee, and others, have seen it in new-born infants; but it is most common in women and aged persons. I have observed it in children at all ages. It occurs more frequently in married than in unmarried females and girls; and is often the consequence of the dis- tention and pressure attending pregnancy, of diffi- cult or instrumental labors, and of suppression of the puerperal secretions, or of the perspiration or catamenia, or of the disappearance of this last evacuation. It appears in both sexes from the usual causes of inflammatory diseases, and the morbific agents to which the abdominal organs are liable, particularly the injestion of cold fluids when the body is perspiring, the use of spirituous liquors, cold, and moisture, and both, or moisture merely, conjoined with marsh effluvia, a poor, watery, or unwholesome diet, or errors in diet, the drastic operation of purgatives, external injuries of the abdomen, and the suppression of accustomed se- cretions and discharges. 90 (6) Pre-existent disease, particularly diar- rhoea or dysentery, and sudden interruptions of these discharges; intestinal worms; organic lesions of the liver and spleen, especially obstructions of their venous circulation; inflammation of the vena porta, and obliteration of one or more of its principal branches; the suppression of chronic eruptions, or of the exanthemata, — as scarlet fever, erysipelas, &c.'—or the premature disap- pearance of the cutaneous affection in this latter class of disorders; acute or sub-acute peritonitis; organic change of the structure of the kidneys; the rupture of cysts into the abdomen; uterine or ovarian disease (§ 35.); intermittent or remittent fevers; excessive evacuation and haemorrhages; are all occasionally productive of effusion in this situation. 91. ii. Pathological States.—Ascites is, 1st, In respect of its structural relations— (a) idiopathic, or primary; (6) consecutive, or meta- static; and (c) symptomatic, or complicated;— 2d, As regards the state of vital energy and vascular action; (a) acute or sthenic; (6) sub-acute; and (c) chronic, passive, or as- thenic. 92. A. The idiopathic form constitutes but a small proportion of the number of cases of ascites met with in practice. Lepois and Morgagni have adduced several instances in which it ap peared soon after drinking large quantities of cold water; and many more may be found in the works of other authors.—(a) The acute, or active, or even the inflammatory state, is that in which idiopathic ascites is most frequently observed. It usually occurs either in the young, the robust, or the well fed, and presents all the symptoms of the phlogistic diathesis : — the pulse is hard, thirst increased, the urine scanty; the skin is warm, hot, or coloured, and resists more or less the pressure of the finger. It commonly pro- ceeds directly from the external agents men- 628 DROPSY OF THE ABDOMEN —Pathology of. tioned above, or from the suppression of an ac- customed discharge, or of some eruption; and often advances rapidly, with symptoms of inflam- matory or excited action in the peritoneum,— with pain, tenderness, and sometimes tension of the abdomen; a quick, small, hard, or wiry pulse, and suppression or diminution of all the secretions and excretions. Either consecutively on, or concomitantly with, these symptoms, ful- ness of the abdomen is observed, which usually augments rapidly. At first the increase is most remarkable in the lower part of the abdomen and iliac regions when the patient is sitting up, and the liver is not enlarged; but it is always diffused when the patient is in the supine posture, and without any limitation or tumour. Upon exam- ining the abdomen by percussion, a somewhat dull sound is emitted, and the examination occa- sions pain. The surface of this cavity is gene- rally dry or harsh, wanner than natural, and more tender to the touch ; and fluctuation is very easily perceived by placing one hand, or the index finger, upon the anterior part of either iliac region whilst the patient is erect or sitting up, and striking gently, at a little distance, with one of the fingers of the other hand. Accord- ing to M. Tarral, a slight effusion will be detected, and the nature of the disease made evi- dent by tills means, long before it reaches the height that can be recognised in the usual way. (See Abdomen, § 16.) As the accumulation augments, all the abdominal functions are more and more disturbed; and at last respiration be- comes difficult, from the pressure of the water upon the liver and stomach, and the impeded descent of the diaphragm; and the patient is unable to lie down. The abdomen is now large and prominent in its upper regions, and pushes, particularly in young subjects, the ribs and car- tilages upwards. Irritability of stomach, anxiety, restlessness, want of sleep, great quickness of pulse, sometimes delirium, and ultimately coma and death, supervene, if temporary or more pro- longed relief be not obtained from treatment. 93. (b) The sub-acute form of ascites is milder in its character and slower in progress than the foregoing; and, as well as the acute, is not an infrequent sequela of scarlet fever, and more rarely of measles ; but is, in such cases, always attended by more or less anasarca. When it thus occurs, it usually appears gradually, and commences from seven to fourteen days from the disappearance of the eruption, commonly with a recurrence of the febrile symptoms, quickness of pulse, dryness of skin, thirst; loaded, white, or furred tongue; and diminution or interruption of the secretions. All the phenomena increase more gradually, however, than in the acute; and are more readily controlled by treatment. In both these forms of ascites, the urine is scanty, often pale, and always contains more or less albumen. The face is generally cedematous in the morning, and the ancles in the evening. In other cases of the sub-acute variety, the effusion takes place upon the disappearance of some acute disease, either attended by free discharges, or treated by copious depletions; frequently with febrile symptoms, and always with interruption or diminution of the natural secretions, the fluid parts of the blood being discharged by the in- creased determination to the peritoneum. In both the acute and sub-acute idiopathic forms of ascites, the accumulation of fluid arises from increased exhalation — hypercrinea of the perito- neum, according to the phraseology of M. An- dral— the result either of morbidly excited vascular action, or of increased determination of blood, conjoined with a relaxed or weakened state of the exhaling vessels and pores. 94. (c) The asthenic, or passive, state of idio- pathic ascites is the most rare. It occurs chiefly after profuse haemorrhages and evacuations; in chlorotic females, or shortly before puberty; in ill-fed persons, Jiving in cold, low, or damp local- ities; and in those who are excluded from the solar light, or are under the influence of the de- pressing passions, and are employed in sedentary occupations. It usually commences with, or is preceded by, oedema of the ancles, feet, and legs. It proceeds very slowly; and is attended by general debility; cold extremities; a pale and sickly countenance; a cold or cool skin; a weak, small, quick, or fluttering pulse; pale or loaded tongue; diminished or vitiated appetite; various dyspeptic symptoms; and by chlorosis or hysteria in females, amongst whom this variety is most fre- quent. The urinary secretion is more copious, and the bowels more irregular, and more readily acted on by purgatives, in this than in the other forms. Whilst lowering measures benefit the two preced- ing, they aggravate this variety of the disease (see § 102.)'. 95. B. Consecutive, or metastatic, asdtes oc- curs in either of the acute or sub-acute states described above; more frequently the latter (§ 93.), when there has been no suppression of the disease on which it is consequent: but, when any of the febrile exanthemata have been prematurely driven from the surface; or when the patient has been exposed to cold or moisture, or both, during convalescence; or if it have supervened upon erysipelas, rheumatism, or gout; the acute or sthenic condition is most common. It is much less acute, if it have supervened upon inflamma- tion of some parenchymatous or adjoining organ; or if it accompany pregnancy. In other respects the characters and progress of the disease are the same as those stated in respect of the idiopathic varieties. 96. C. The symptomatic, or complicated, states of ascites are the most common; and, like the primary or idiopathic, present every grade of activity and acuteness. But whilst, in the latter, the acute and sub-acute are most frequent, in the symptomatic, the asthenic state predominates; although an irritative form of inflammation is sometimes observed to occur in the course of the disease, often, probably, owing to the irritating properties of the effused fluid, as shown above (§ 34.). Complicated ascites presents many of the organic lesions that occasion symptomatic dropsy (§ 12.); most commonly structural changes in the liver, or vena porta; in the spleen; in the mesen- tery and its glands; in the kidneys; in the uterine organs; and in the veins and lymphatics. The dropsical collection appears after a longer or shorter period of disease referrible to these organs; commences imperceptibly, and proceeds slowly; and generally without febrile symptoms until towards the fatal close of the disease. Fre- quently oedema begins in the feet, and extends upwards to the knees, thighs, scrotum, or hips, DROPSY OF THE ABDOMEN —Diagnosis of. 629 and as high as the iliac regions and loins. But ascites often reaches its acme without any ana- sarca or oedema. As the accumulation increases and rises up into the epigastric region, the symptoms become more urgent, —the respiration more quick, short, and difficult; the pulse more rapid; the functions of the stomach more dis- ordered; the alvine evacuations longer retained; the urine more scanty, higher coloured, and more turbid — often brown and foetid; the skin drier; aud the face, and other parts which are not oedematous, more emaciated. In this form of the disease, the veins of the abdominaf parietes often enlarge and become very apparent; a symptom which M. Retneaud found dependent, in several cases, upon obstruction or obliteration of the vena porta; the sub-cutaneous veins of the ab- domen having been enormously dilated. When the effusion arises from disease of the substance ofthe liver, it is not infrequently associated with some degree of jaundice. With great distension of the abdomen, distressing borborygmi occur, and aggravate the symptoms. The anxiety, debi- lity, restlessness, and inability to sleep increase; and in some instances, hydrothorax or anasarca, or both, either with or without a diminution of the abdominal accumulation, supervene in this stage of the malady. The fatal close of the disease is generally ushered in by somnolence, or by delirium followed by somnolency; by urgent thirst and dryness of the mouth and throat; by vomitings or retchings; by leipothymia; small, frequent, and irregular or fluttering pulse. The duration of this form of ascites is extremely va- rious: it may continue for years, or it may run its course in a few days. In this latter case, either the kidneys are very seriously diseased, or the circulation through the vi-na porta is obstruct- ed. The complication of ascites with pregnancy will be considered in the sequel. 97. iii. Appearances in Fatal Cases.— (a) The effused fluid varies greatly in quantity and appearances. It is usually of a pale citron or yellowish tint; sometimes greenish, or even brown. When it has arisen from obstruction in some adjoining viscus, as in the passive states, it is generally limpid and nearly transparent; but when it has proceeded from disease of the peri- toneum, as in the acute forms, or from sub-acute inflammation, it is turbid, whey-like, contains albuminous flocculi, or pieces of filamentous lymph, or even thin or partial adhesions. In some cases the fluid exhales a foetid or urinous odour, and it is occasionally of a brown, or nearly black- ish hue, from the exhalation of some of the colour- ing particles of the blood.—(b) The peritoneum presents, in different cases, all the changes al- ready described (§ 10.). Sometimes it is covered by a thin albuminous or muco-albuminous coating, or is adherent in parts. In other cases it is soften- ed, thickened, blanched, and as if macerated; and in some granulated, or tuberculated (Bichat, Barron, Andral). The omentum has occasion- ally nearly disappeared (Morgagni, Pezold, De Haen, &c); or it is pushed up towards the stomach (Osiander, myself, and others); or ad- herent in parts to the intestines, or to the abdominal parietes (Ribe, Andral, &c); or suppurated, thickened, and indurated (Stoerck,Osiander, &c). It has likewise contained steatomatous or other tumours. The mesentery is sometimes also 53* diseased. Its glands are very frequently enlarged; and tumours of various kinds have been found in it by Tulpius, Harder, J. P. Frank, Von Berger, Alix, Andral, myself, and others. The pancreas has been seen enlarged and scirr- hous, but it is not often altered in structure. The liver is most generally diseased. The vena porta has been found obstructed by coagulable lymph, the product of inflammatory action, and even altogether obliterated, by Reyneaud; or pressed upon by tumours, or its circulation impeded or interrupted by atrophy, or by enlargement, or by induration of the substance of the organ; or by scirrhous, granular, or tubercular degenerations of its structure (see liver). The gall-bladder and hepatic ducts have been found containing biliary concretions, by Morgagni, Hoffmann, Sto- erck, Marteau, and others; and in some in- stances distended by a black and thick bile; or containing a small quantity of pale mucous bile, by the same authors, as well as by Ridley, Pe- zold, Duverney, Yonge, and several recent writers. The kidneys have also been often seen diseased as described above (§ 13.); and the spleen is very frequently enlarged, indurated, and other- wise changed (Selle, Schmucker, Horn, (Jrottanelli, and myself), as described in that article, especially in the abdominal dropsies that oc- cur in low, moist,warm, and miasmatous localities. 98. iv. Diagnosis.—A. Ascites may be mis- taken for tympanites, for the various kinds of encysted dropsy, and for pregnancy.—(a) Tym- panites is readily recognised by the clear resonance furnished on percussion; by the absence of fluctu- ation, and of oedema of the lower extremities; and by the history of the case. —(b) Ovarian dropsy is generally preceded by pain, tenderness, and tumefaction, or distinct tumour in the regions of the ovaria; and the enlargement proceeds from one or both these parts. It is never general or uniform in its earlier stages, as in ascites; and fluctuation is usually very obscure, and to be de-< tected only in the situation, of the tumours, the circumscribed form of whicn may be determined until a very advanced period of the disease. In- stances, however, occur, in which the ovarian tumour induces effusion into the peritoneal cavity: in this case, the exact nature of the disease can be ascertained only from a knowledge ofthe pheno- mena attending its early stages, or of those con- sequent upon tapping; the letting out of the ascitic fluid generally allowing the ovarian disease to be readily detected. The same remarks apply to dropsy of the Fallopian tubes, which are at- tended with nearly the same phenomena as the ovarian disease.—(c) In hydrometra, or dropsy of the uterus, fluctuation is with difficulty ascer- tained; and cannot be detected in the iliac regions, by the means described above (§ 92.); besides, the form of the uterus may be defined upon a careful examination; the progress of the affection is usually much slower than in ascites, and there is much less disturbance of the general health. There are, moreover, entire obstruction of the catamenia, and a sense of heavy pressure on the rectum, bladder, and adjoining parts. — (d) Cysts containing a watery fluid, and of great size, are sometimes attached to the liver or to the spleen, giving rise to appearances in their advanced states closely resembling ascites. But they al- ways present a circumscribed tumour upon ac- 56 630 DROPSY OF THE ABDOMEN—Treatment of. curate examination, the swelling commencing on one side, generally in the upper regions of the abdomen, whilst ascites begins, when the patient is up, in the lower, and is equally diffused when he is supine.—Of encysted dropsies, generally, it may be remarked, that a heavy weight, sometimes with dragging pain, is commonly felt when the patient turns in bed, particularly to the opposite side to that to which the cyst is attached; and that he usually lies on the latter side. When only one large cyst, containing a watery fluid, exists, the diagnosis is sometimes very difficult, un- less the history of the case is known, particularly in respect of the last stages of some kinds of ovarian dropsy. In rare instances, several cysts are attached to different parts of the same viscus, or even to different organs, or to the abdominal parietes. But very much more frequently the dropsical ovarium, or ovaria, is very irregular and lobular, owing to its division into several distinct cysts. In all such cases, the abdomen, upon an accurate manual examination, will feel more or less irregular and unequal, and the nature of the disease be nearly manifest. M. Piorry states that a duller sound is emitted upon percussion in encysted dropsies than in ascites; and that the parts around the cysts furnish the same sound as in health. The progress also of encysted dropsies is always slow, and their duration fre- quently very long. They are commonly unat- tended by much constitutional disturbance until they reach a very great height, so as to press injuriously upon the stomach, and to impede the functions of respiration, when hectic fever is often developed: the secretions and excretions, and even the quantity of the urine, not being much diminished or disordered until then (see Dropsy —Encysted). —(e) Pregnancy is distinguished from ascites by the state of the os uteri upon ex- amination, by the progress of the enlargement, and the defined form of the uterus, when the patient is supine, and the abdominal muscles re- laxed; by her unbroken health and clear com- plexion, — the countenance of dropsical persons being pale, sickly, and cachectic; by the en- largement and firmness of the breasts, and the deep colour of the areolae, — these organs being soft and flaccid in ascites. (See Pregnancy.) 99. B. It is not enough that we should satisfy ourselves as to the exact situation of the effused fluid, but we should determine as correctly as pos- sible the pathological condition giving origin to it. In order to do this, we should endeavour to con- nect it with its exciting causes, and to enquire into the external agencies concerned in its ap- pearance, and the conditions of the various secreting and excreting organs. The manner of its accession, the rapidity of its early progress, the sensations of the patient previously to this event, and the several phenomena furnished by an ac- curate manual examination, as well as a rational consideration of all the natural functions, in con- nection with external signs, must be our main guides in coming to a conclusion relative to the alteration or alterations, functional and organic, upon which it chiefly depends. The rapid in- crease of the swelling after exposure to cold or any ofthe usual causes of inflammatory disorder, or after the suppression of discharges or of erup- tions; a sense of tension or pain in any of its regions; increased sensibility upon examination by percussion, or in any other way, especially in the hypochondria, in the loins and uterine region, demand particular attention; and the urine should be daily examined, and its coagulability noted. The size ofthe abdomen should also be observed daily, and the decrease and increase marked by a tape measure. 101). v. Prognosis.—The prognosis in ascites must necessarily depend upon its form and com- plications, upon the habit of body, and constitu- tional powers of the patient, and the effects of remedies. A much more favourable opinion of the result may be formed when the disease is primary, occurs in young and previously healthy persons, or follows scarlet fever or measles, than when it proceeds from organic change either in the liver, kidneys, ovaria, or other abdominal viscera. In cases of this latter description, very few recover permanently. Swelling ofthe hands; emaciation of the arms; frequent cough; very scanty foetid and thick urine; colicky pains; the presence of jaundice; and the occurrence of hic- cup, vomitings or diarrhoea; are very dangerous symptoms. The appearance of aphthae, of con- vulsions, of livid blotches on the extremities, par- ticularly on the hands and forearms, are commonly fatal signs, as justly insisted on by Hippocrates, Forestus, Frank, and others. Somnolency, great irritability of stomach, a pulse above 120 or intermittent and small, and delirium, are not less unfavourable (see § 37.). The characters of the fluid let out by tapping also indicate the result. If it be thick, foetid, brown, glutinous, or albumi- nous, no permanent advantage will be derived from the operation. 101. vi. Treatment.—But little in addition to what I have already stated may be said of the treatment of ascites.—A. Its acute or sub-acute idiopathic states require vascular depletions, ge- neral or local, or both, and the rest of the antiphlogistic regimen, to an extent which the pulse and symptoms, and circumstances of the case, will indicate. In ascites occurring in child- ren after the exanthemata, local depletions will be sufficient, but if leeches be applied, their punctures should be carefully watched; for there is often great difficulty in arresting the haemor- rhage from them after these diseases. Mercurials and antimonials, at first so as to act upon the bowels, and subsequently as alteratives, or with opium, and pushed as far as to affect the mouth; external irritants and derivatives; deobstruent diuretics, and digitalis — this last particularly in the ascites consequent on scarlet fever; diapho- retics and warm or vapour baths, followed by oleaginous frictions ofthe skin, in order to restore its perspiratory functions; and, lastly, gentle tonics conjoined with purgatives, or with diuretics, and assisted by warm iodine or medicated baths, will frequently succeed in removing disorder, if early employed, and if a vital organ have not expe- rienced serious structural change. Upon the whole, these forms of ascites should be treated as described at length in a preceding chapter (§40.). 102. B. The asthenic form of primary ascites (§ 94.) is most readily removed by the tincture, or other preparations, of iodine; by the ferrum tartarizatum with cream of tartar; by the combin- ation of purgatives with tonics, as Bach •: r's pills; or of tonics with diuretics; by warm salt-water bathing; warm medicated baths, particularly DROPSY OF THE ABDOMEN —Treatment of. 631 those with iodine or aromatic herbs ; and frictions of the surface with stimulating liniments. The gentler vegetable tonics should be first employed, and subsequently chalybeates and the more active tonics, as bark, gentian, &c. ; and these may be conjoined with acids, particularly the sulphuric with spiritus aetheris sulphurici, or the nitro- muriatic with spiritus aetheris nitrici, and other diuretics ; and alternated or associated with the rest ofthe treatment recommended above (§ 42.). In this, and other forms of asthenic ascites, J. P. Frank advises the exhibition of full doses of opium,— a practice from which I have seen much benefit obtained after morbid secretions had been evacuated by purgatives as now prescribed. I have, however, usually combined the opium with diuretics and tonics. Dr. Graves, whilst he adopts this part of Frank's practice, recom- mends, in addition, the free use of animal food, which Ls doubtless requisite in many instances, par- ticularly when the effusion has arisen chiefly from a poor or thin diet, and other depressing causes. 103. C. The metastatic form of ascites requires a similar treatment to that directed for the acute and sub-acute states (§ 40, 41.), together with means to restore the primary affection. Counter- irritation of an active kind, and long persisted iu, as well as appropriate to the nature of the disease on which it has supervened, will often prove beneficial. The repeated application of moxas has been for ages commonly resorted to in ascites in the eastern countries of Asia, and has more recently been found useful by some Continental physicians. Several moxas are usually directed to be placed around the umbilicus, or over the hypochondria, or upon the loins, according as the functions of the liver or kidneys appear to be most obstructed. Sulphureous, vapour, iodine, aud other medicated baths, seem calculated to prove beneficial in this, more than any other form of the disease. In this variety, also, the oxy- murias hydrargyri may be taken in the com- pound decoction of sarsaparilla, with colchicum or squills ; or the ioduret of mercury may be cautiously exhibited, in small doses, with digitalis and extract of conium. . When the disease has followed the suppression of the catamenia, the preparations of iodine*, much diluted, or the * I was consulted, some years ago, respecting a case of ascites consequent upon profuse and frequent menstru- ation. This discharge had been suppressed bv exposure to cold; and, soon afterwards, symptoms of inflammation of the serous co.ering of the liver, with effusion, were ob- served. These were combat d by local depletions, which were repeated : by external irritants, by me curials, and, subsequently, by cream of tartar with borax and diu- retics, and other means in various forms of combination ; but without any permanent benefit. I directed at last a weak solution of the hydriodate of potash with iodine ; and caused it to be persisted in for seven or eight weeks, when good effects began to appear. This medicine was con- tinued for five or 'ix months; at the end of which time the catamenia had become regular, and' the effus on had en irely di-appeared. I was more recently consulted as to .i simi ar case, in the care of Mr. Grabham, ol Roch- ford; which had, likewise, been preceded by profuse catamenia, suppression of this discharge followed by pul- monary disease, and extention of tenderness and fuliess from ihe thorax, over the region of the Ii.er ;md abdo- men; with e/fusion of fluid into ihe abdoninil cavity. The pulmonary affection and the more acute symptoms subsided under the very judicious practice of this g'cntlo- inan i hut the means successive y adopted in consultation failed of removing the dropsical collection, and of arrest- ing the progressive emaciation. There wis also, in this case, scrofulous disease of one or two of the metacarpal bones of the left hand. This was 1 ft to itsef, in hopes supertartrate of potash, with an equal quantity of borax, and sulphur, have succeeded in restor ing the suppressed evacuation, as well as in removing the disease. 104. D. The symptomatic, or complicated, form of ascites must be treated according to the principles laid down (§ 44. et seq.), and with strict reference to the original lesion or malady, as far as that can be ascertained. The remedies, perhaps, the most to be depended upon, are purgatives, alteratives, and diuretics ;—calomel, elaterium, croton oil, camboge, jalap, &c, va- riously combined ; the nitro-muriatic acids, in- ternally with the compound decoction of sarsa- parilla, and externally in the form of bath or lotion ; saline substances, with taraxacum ; the preparations of iodine in small but frequent doses, much diluted, long presisted in, and associated with narcotics, particularly opium, or lactuca- rium, or conium ; cream of tartar or acetate of potash, variously combined, especially with squills ; and, subsequently, the decoction of broom tops (F. 75.), or of pine tops (F. 51.), or the decoctum cydoniae compositum (F. 57.) or the decoct, inulae comp. (F. 67.), or the infusum berberis (F. 225.), with one or more diuretic medicines. Cream of tartar was found most successful by Dr. Home ; and, if given in suf- ficiently large doses, conjoined with substances suitable to the complications of the case, and continued sufficiently long, is the most certain remedy that can be prescribed. I have usually exhibited it, in this state of the disease, in doses of from two drachms to half an ounce, in the form of electuary, with an aromatic powder and diuretic medicine. In this form it generally acts freely on the bowels, and sometimes, also, increases the flow of urine. Terebinthinate in- jections, and oleaginous frictions, as already di- rected (§ 65.), are also useful adjuvants. In some states of ascites, advantage may be derived from the internal exhibition of cantharides. J. P. Frank has seen cases where it has effected a cure ; yet he considers it the most uncertain medicine that can be prescribed. Graduated compression of the abdomen, by means of the belt recommended for ascites by the first Munro, has been employed sucessfully by Professor Speranza and M. Godelle ; and, when it can be borne, may prove serviceable in some asthenic and chronic states of the disease. Riverius recommends poultices of the bruised charlock, the raphanus raphanistrum, to be placed over the loins or upon the abdomen, and to be fre- quently renewed. Bran poultices are also in com- mon use. The warm medicated baths, already no- ticed, are calculated to be of service, when assisted by sudorifics. But these last cannot be depended upon unless they be combined with opium. Hence the occasional good effects of Dover's powder In some cases, an increased porportion ofthe ipe- cacuanha will be useful. I have seen benefit de- rived from the following, when the stomach was thit the d scharge from it would have had a salutary effect on the principal seat of disease. In summer, 1832, this young lady came to London, where various remedies were prescribed, without relief. I then put her upon a course of iodine; and, directing her to persist in its use, advised her return to the country. I haie since under- stood that, during (he use of this medicine, the effusion disappeared, and the catamenia returned; that she re- covered her looks, and is now married. 632 DROPSY OF THE ABDOMEN —Treatment of. not irritable, or when its contingent effect of causing vomiting would not be injurious. No. 185. R Pulv. Ipecacuanha; gr. ij. ad iij.; Camphors; Subactae sir. j.; Pulv. ( pii Puri gr. j ; Potassae Nitratis et Pulv. Radic. Glycyrrh. aa gr. x. M. Fiat Pulvis quovis in vehiculo idoneo sumendus ; vel sit bolus cum Conserv. Ros., et bis terve in die capiendus. 105. Paracentesis is the last means to which recourse should be had. I took occasion, many years ago, in the London Medical Repository, to differ from those who advise either an early or an indiscriminate recourse to this operation, and for reasons about to be stated. It has, however, had , many advocates, from the earliest period of the art, and probably originated in the benefit, in some cases, derived from the spontaneous rupture ofthe umbilicus and discharge ofthe fluid. The empirical manner in which it was resorted to during the fifteenth and sixteenth centuries had brought it into disrepute.when Mf.ad,Delius,Banyer, Stoerck, Schmucker, and some others, wrote in favour of it, and endeavoured to establish it on a more rational basis. Hautesierk expressed himself favourably of it, and advised purgatives and tonics to be perseveringly prescribed after its per- formance. Fothergill conceived that its want of suocess arose from its being too long delayed, and directed it to be resorted to early. In the present day it is certainly more frequently per- formed than circumstances appear to me to war- rant ; and although it should not be proscribed from practice, I believe that the cases are few that will be benefited, and still fewer that will be cured, by it. The chief objections to it are founded on its being inappropriate in a large num- ber of cases, on its liability to induce inflamma- tory irritation in the peritoneum, and on the fa- cility with which air may enter the abdominal cavity during the usual mode of performing it. On these topics I will add a few words. 106. 1st. Paracentesis seems calculated to in- crease the mischief, and to diminish the chances of a complete cure, in acute and idiopathic ascites, either by increasing inflammatory irritation, where this already exists, or risking its supervention in the asthenic forms of the malady. When ascites depends upon altered structure of the kidneys, it will seldom do more than give temporary relief; and a similar remark applies to the complication with disease of the liver. This advantage is, however, worth procuring, and is sometimes con- siderable, especially when a more decided effect is produced by medicines, as is sometimes the case, after the abdominal distension has been removed by it. But unfortunately this result is not always obtained ; for inflammatory irritation often extends from the punctured part, owing to the readiness with which an asthenic or erysipe- latous form of inflammation follows punctures of serous surfaces, in a cachectic habit of body, and particularly when the functions of either the liver or the kidneys are obstructed ; and thus, in addi- tion to the original structural lesions, disease is superinduced in the peritoneum, and the effusion is renewed with greatly increased rapidity. This complication is, moreover, favoured by the ef- fects of the fluid upon the wound in the perito- neum ; for, as I have already shown, this fluid, owing to interruption ofthe depurating functions, is often possessed of properties which induce in- flammatory irritation in the healthy peritoneum, and which are more likely to have a similar effect when this membrane is punctured or otherwise divided. 107. 2d. The introduction of air into the ab- dominal cavity, although frequently unattended by any inconvenience in a healthy state of the frame, and particularly when the peritoneum and adjoining viscera are not in a morbid or irritable condition, is certainly sometimes productive of very serious and even fatal effects, especially in that state of the constitution and of the abdo- minal organs, in which ascites commonly pre- sents itself. I believe that this inference is conformable to the experience of the most en- lightened pathologists. The instrument, also, with which paracentesis is usually performed, al- though calculated to facilitate the removal of the fluid, favours the introduction of air. The wound it inflicts is such as to prevent the immediate closure of the aperture in the peritoneum ; and in some instances this membrane is pushed before its point so far as to detach it to some extent from the abdominal parietes,— circumstances which, when viewed in connection with the cachectic habit of body, weak powers of restoration, and morbid state of the accumulated fluid, are cer- tainly favourable to the occurrence of asthenic inflammatory action, and its consequent effusion, after the operation. On this account, therefore, paracentesis may be perferably performed by the lancet, as recommended by J. P.Frank ; or, after the abdominal parietes are divided by the scalpel, the lancet may be pushed through the peritoneum, a bandage placed around the abdo- men being tightened as the fluid passes off, and care being taken to close the aperture with ac- curacy as soon as the stream begins to cease. But even in this manner the operation is not likely to prove of much service, where there is tenderness of the abdomen. Many of the cases of recovery imputed to paracentesis, I am con- vinced would have taken place without it, under an appropriate treatment ; whilst, doubtless, be- nefit has been derived from it, both of a temporary and permanent kind. Instances certainly some- times present themselves, in which the symptoms are so urgent that it would be culpable to neglect having recourse to it. It should, however, be the ast resource. In ascites appearing during preg- nancy, it, or puncturing the foetal membranes, is both requisite and successful; although in two such cases, in which I was consulted, the means hereafter to be noticed prevented the necessity of performing either. It is unnecessary to state the number of times the operation has been performed, and the quantity of water removed either at once or altogether. Extreme instances are comparatively rare, and convey no useful information. On this subject I will only add further, that tapping through the umbilicus has been recommended by Dr. Sims, and several other writers; that it has also been advised to perform the operation through the vagina ; and through the bladder, by Dr. Buchannan. The objections to the second and third of these are very obvious; and, as respects the last, the risk of urine escaping into the peritoneum must put it out of the question. The recommend- ation of conveying astringent fluids, or vapours, [ into the cavity of the abdomen, advocated by a few writers, both British and Continental, abont ' the end of the seventeenth and beginning of the DROPSY OF THE ABDOMEN — Puerperal — Treatment. 633 eighteenth centuries, merely shows that medical and surgical temerity is not a result of science, but of its earliest dawn. 108. The diet and regimen in ascites is the same as that briefly noticed above. In the more asthenic states, a liberal diet of animal food of a light and nutritious kind is requisite, in addition to a tonic treatment; and much benefit will sometimes ac- crue from allowing the patient the use of malt liquor, or gin-punch, in moderate quantity, and from making either of them the vehicles for the exhibition of diuretics, with gentle tonics, or adding them to some one of the diuretic drinks in the Appendix (F. 588. et seq.). In cases of this description, Recipe 781., or the following, recommended by Richter, may likewise be used:— No. 186. R Rad. Scillae Recent. 5§ j. ; Cort. Aurantii, Radicis Calami Arom., aa ^ iij. ; Juniper. Baccar. con- tus. 5 ij- i Vini Albi Hispan. lb. iv. Digere per dies tres, cola, et adde Oxyinel. Scillae 5 ij. M. 109. IV. Puerperal Ascites.—i. Pathol- ogy.—The more frequent occurrence of ascites in the female sex has been partly attributed to the influence of the female organs in giving rise to it (■§ 35. 89.), independently of the puerperal states. But effusion into the peritoneum may occur either (a) during pregnancy, or (b) after delivery.—A. The association of ascites with pregnancy has been noticed by several ofthe older writers, and by many of the moderns, and is not an infrequent occurrence. Either impregnation may take place during the dropsical disease, which is very rarely the case; or the effusion may be excited by pregnancy, being favoured by pre-existing obstruction in the liver, or a ple- thoric state of the system. This latter is the com- mon mode of its appearance. It is generally of a sthenic or plethoric character, and is often associated with impeded circulation through the liver, or the right side of the heart; although it may be occasioned solely by changes induced by iitero-gestation, and independently of visceral dis- ease. In this latter case, the ascites seldom com- mences until about the third month. When it exists, the form or even the body ofthe uterus often cannot be ascertained by a careful examination of the abdomen, unless with difficulty, when the pa- tient is quite supine, with the hips elevated. The hypochondria become enormously distended and elevated as the effusion and pregnancy proceed. The urine is lateritious, scanty, and of a high colour; and there is much thirst, and pains in the back, loins, and thighs. Scarpa states, that fluctuation is obscure in the hypogastric region and flanks, but distinct in the hypochondria, par- ticularly in the left. The state ofthe os uteri, the patient's sensations, and the history of the case, will generally enable the practitioner to decide as to the nature of the complication and the period of pregnancy. This state of disease becomes remarkably distressing. The patient is afflicted by dyspnoea; and by cramps, pains, and cedematous swellings of the lower limbs, from pressure on the nerves and vessels supplying them, and by sickness and vomitings. She is unable to ascend the stairs, or to lie down in bed. The bowels are very constipated, and the breathing short and difficult; to these often are superadded great anxiety, lividity of the lips and counte- nance, heavy and somnolent headach, leipothy- mia, palpitations, and other symptoms indicating the propriety of having immediate recourse either to paracentesis, or to the rupturing of the mem- branes. When the disease is dependent upon obstruction or structural lesion of the substance of the liver, & fatal issue often takes place soon after delivery, whether that have been premature or at the full time. But when it is occasioned chiefly by the changes in the nervous and vas- cular systems, and state of the circulation con- nected with pregnancy, a favourable termination may be expected. Scarpa, Desormeaux, and Le e , record cases, in which this disease was still further complicated with dropsy of the amnion (§ H5.). 110. B. Ascites more frequently occurs sub- sequently to delivery, but at no definite time; either in a very few days, or not until some weeks, or even months, afterwards. It may either be a sequela of the adynamic form of puerperal fever, of which I have observed two cases; or of peritonitis; or of inflammation of the uterus, ovaria, or of their veins, occurring at this period. It may likewise be induced by suppression of the lochia; or by a diarrhcea which has been suddenly arrested before disordered secretions and accu- mulated faeces have been evacuated; or which has been long neglected, or injudiciously treated. It is generally acute or sub-acute, when it ap- pears in this manner; but if it occur in females who have been ill-fed, or who have experienced large losses of blood about the period of labour, it possesses very different features. 111. ii. Treatment.—(a)Ascites associated with pregnancy is seldom benefited by diuretics. In two cases which came under my care, and presented the symptoms described above, early, repeated, and moderate vencesection; a gentle and constant action upon the bowels by cream of tartar and confection of senna; and full doses of opium, assisted by various other means directed according to the symptoms; carried both patients to about the full period of gesta- tion; and both bore living children. After de- livery, the rapidity with which the water passed off by the kidneys was surprising. In one of the cases, three large chamber utensils were filled in twenty-four hours. Paracentesis was urged by the ordinary medical attendant in one of these, but was delayed as a last resource: it was not performed in either. Utero-gestation very seldom reaches the full time, when fluid is effused into the abdomen, whether the operation be resorted to or not. Scarpa advises its early performance, and adduces a case in which this complication was aggravated by dropsy of the amnion, and in which it was performed under the left false ribs, and the patient recovered. It was also resorted to successfully in the one recorded by Mr. Langstaff. In M. Desormeaux's case there were ascites, dropsy ofthe amnion, and anasarca. He punctured the membranes, and brought on labour. The instance adduced by Dr. R. Lee resembled that mentioned by Scarpa. The cervix uteri being obliterated as in the ninth month of pregnancy, he ruptured the membranes, and brought on labour; after this the patient slowly recovered. 112. (6) As to the treatment of asdtes oc- curring soon after delivery, the same means, ap- propriately to the circumstances of the case, as 634 DROPSY OF THE AMNION —Treatment. have been already described, are to be put in practice. The great majority of such cases will recover under judicious management, if the liver or uterine organs be not very seriously diseased. Paracentesis is very seldom required; and I be- lieve the risk of performing it to be greater in this state of the disease, than in any other, from its liability to induce asthenic inflammatory action in the peritoneum, and to increase it if it be already present. I may add, that instances have occurred in which air has been extricated from the decom- position of the animal matter in the fluid effused, particularly when the disease has depended upon atonic inflammatory action in this membrane, aud thus the ascites has become complicated with true tympanitis. This is more likely to occur, after paracentesis has been employed in a case of this description. (See Author, in Lond. Med. Repos. vol. xvii. .p. 378.) Bibliog. AND Refer.—i. Avicenna, Canon. 1. iii. fen. 14. tr. 4. cap. 5. et seq.—Tulpius, I. ii. cap. 33.—Riverius, Praxis, 71.—Ruysch, Observ. 70. (Ossification of vena por- ta.)—Yonge, in Philosoph. Trans. No. 333.—Morgagni, De Caus. et Sed. Morb. ep. 38. art. 20—34.—F. Hoffmann, De Hydrope Ascite. Halae, 1718.; et Consult, cent. ii. No. 70. —Coschwiz, De Virgine Hydropica, Uteri Mola simul labo- rante. Halas, 1725.—R. Mead, Monita et Prascepta Medica, cap. viii. p. 31.—Pezold, Observ. Med.-Chirurg. obs. 65., et obs. 77.—Jacquart, Non ergo Hydr. Paracentesis. Paris, 1752.—Boehmer, De Utilitate Paracent. frequent, in Ascite. Halae, 1759.—Cartheuser, De Hydr. Abdominis Vario. Fr. 1760.—Stoerck, Ann. Med. t. i. p. 129., et t. ii. p. 265.— Vogel, Hydropis Ascitis Semeiologia. Goet. 1764.—Linnaus, De Morb. Naut. Indiae. Ups. 1768.—Alix, Observ. Chirurg fasc. iii. p. 1.—De Haen, Rat. Med. par. v. p. 40.—Lieu- taud, Hist. Anat. Med. t. i. p. 3.—Lentin, Beytr&ge, kc, p. 180.—Pringle, in Edin. Med. Essays, vol. iii. p. 378.— Monro, in Ibid. vol. iv. p. 428.—Sauvages, Nos. Meth. vol. ii. p. 498.—Hunter, in Med. Observ. and Inquir. vol. ii. No. 2.—Fothergill, in Ibid. vol. iv. p. 114.—Mackenzie, in Ibid. vol. i. p. 146.— Selle, N. Beitrftge, b. ii. p. 17.—Von Berger, Act. Reg. Soc. Med. Haun. vol. i. p. 248.—Young, in Duncan's Ann. of Med. vol. i.—Sims, in Mem. of Med. Soc. of Lond. vol. iii. n. 27.—Warner, in Ibid. vol. iii. p. 588.—Flajani, Collez. d'Osservazioni, t. iii. osi. 25., t. iii. oss. 55.—Albers, De Ascite, June, 1795.—Thomunn, Anna- len ad 1800, p. 357.—Maclean, in Med. and Phis. Journ. 1802.—Marteau, in Journ. de Med. t. xxviii. p. 328,-r- Des Hydr. Ascites et Leucophlegmasies qui regnent dans les Marais de la Vendue. Paris, 1804.—Wi/hch, De Paracenttsi Ahdom. in Hydrope. Goet. 1804.—Richter, Die Specielle Therapie, kc. b. iii. p. 26.—M'Loughlin, Trans, of Irish Coll. of Phys. vol. i. p. 199.—S. Grottanelli, Splenis Mor- bi, kc. 8vo. Flor. 1821, p. 117. (Enlargement of spleen with chlorosis and ascites.)—L. Rostan, in Nouv. Journ. de Mid. t. iii. p. 215. (On the diagnosis of ascites.)—Godelle, Nouv. Biblioth. Medic, t. vii. p. 5., et t. vi. p. 34. (On com- pression in.)—Speranzu, Archiv. G£ner. de Med. t. xvii. p. 604.—Landre'-Beauvais, in Diet. de. Medecine, t. iii. p. 49. —J. J. Leroux, Cours sur le Gentralite- de la Med. Pra- tique, t. iv. p. 6.—Venables, in Lond. Med. Gazette, vol. v. p. 397.—J. Bouillaud, in Diet, de Mid. et Chir. Prat. t. iii. p. 524.—G. Andral, Clinique Medicale, kc. t. iv. p. 269. et seq.—Reyneaud, in Journ. Hebdom. de Mid. t. iv. p. 137.—A. Buchanan, in Glasgow Med. Journ. vol. i. p. 195.—Elliotson, in Lond. Med.Gazette, vol. vii. p. 313.; and Ibid. vol. ix. p. 571. 617.—Graves, in Ibid. vol. vii. p. 584. ii. Puerperal Ascites.—Rhuysch, Observ. Chirg. So. 70.—Berchelmnnn, De Ascite cum Quartana in Gravida. Giess. 1752.—Mauriceau, Traite des Maladies des Femmes Grosses, vol. ii. p. 59. 204.—Boehmer, De ( omplicata, cum Abdominis Hydrope Graviditate, ejusque Signis. Hdlae, 1770. —Chambon, Maladies des Femmes, t. i. p. 28.—Barai/ton, in Mem. de la Soc. R. de Med. an. 1784, 1785.—Laurin, in Med. Observ. and Inquir. vol. v.—Osiander, Beobachtun- gen, kc. p. 114.—J. P. Frank, De Curand. Homin. Morb. vol. vi. pars i. p. 278.—Scarpa, Sulla Gravidanza Su sequita de Ascite, kc. Trev. 1817.; et in Journ. of For. Med. vol. i. p. 249.—Lar.gstaff", in Transac. of Med. and Chirurg. Society of Lond. vol. xii. p. 372.—J. Burns, Principles of Midwifery, 6th ed. p. 238.—Desormeaux, in Diet, de Mid ecine, vol. xi. p. 391.—Portal, Observat. sur la Nature et le Traitement de l'Hydropisie. vol. i. p. 213.—R. Lee, in Lond. Med. Gazette, vol. vii. p. 387. V. Dropsy of the Amnion. — Hydrops Amniosis, Mercier ; Hydrops Amnix; Hy- drometra of Pregnant Women, Desormeaux. 113. Defin. The preternatural distention of the uterus, by an excessive secretion of liquor amnii, giving rise to symptoms of ascites, some- times ivith obscure fluctuation. 114. i. Pathology. — A morbidly increased secretion may take place, 1st, within the amnion; and, 2d, between the membranes and uterus. The former usually occurs during advanced utero- gestation; the latter in the early months, and generally passes off without occasioning any dis- turbance as pregnancy proceeds. The excessive accumulation of fluid in the cavity of the amnion was first accurately described by M. Mercier; and it was imputed by him to inflammatory action in this membrane. It has more recently been noticed by MM. Maunoir, Duclos, and Desormeaux; but the researches of this last phy- sician have not confirmed this view of its origin. Dr. R. Lee has recorded five cases, in none of which were any inflammatory appearances in the amnion, and only in two were there in- flammatory or dropsical symptoms in the mother. But in all of them, some malformation or dis- eased condition of the involucra, or of the foetus, existed, and rendered it incapable of supporting life subsequently to birth. It is sometimes con- nected with a dropsical diathesis in the mother; but is more frequently entirely dependent upon disease of the foetus and its envelopes. It pos- sibly may also depend upon an affection of the uterus itself, as hinted by M. Desormeaux. 115. The Diagnosis of dropsy of the amnion in its simple form, and where the quantity of fluid is not very great, is difficult. Fluctuation is obscure, deep seated, or wholly imperceptible. On examination, however, per vaginam, the body of the uterus is prematurely enlarged; the cervix is almost entirely obliterated; and there is a sense of fluctuation in the vagina upon percussion of the abdomen. The rapid increase of the uterus, the gravative pain in its region, the feeling of weight and pressure in the pelvis, the frequent calls to evacuate the bladder, and scanty secre- tion of urine, will further guide the practitioner. The diagnosis, however, will be rendered more difficult if it be complicated with ascites, as in the instances recorded by Scarpa, Desormeaux, and Dr. Lee. In this case there will be fluc- tuation on percussion, but this will be no sure information as to the situation of the effusion. The progress of the enlargement of the uterus, and the result of vaginal examination, in con- nection with an attentive manual investigation of the abdomen, alone can furnish correct indi- cations as to the nature of the disease. 116. ii. Treatment.—The chief intentions are to relieve urgent symptoms, and to carry the patient safely, if possible, on to the period of delivery (Desormeaux and Lee). These ob- jects may be attained by the treatment I have already advised (§ 111.), when the constitutional powers will admit of it. But if the symp- toms become urgent, and the functions of the stomach entirely overturned, the advice of Desormeaux to puncture the membranes and induce delivery should be followed; when the disease will be remedied, if not complicated with ascites; in which case, the means already de- scribed must be practised. DROPSY OF CELLULAR TISSUE — CEdema. 63b BlBLIOG. and Refer.— F. Mercier, De Acute Am- niosis Hydrope, aut Amniosis Inflammatione quae evasit in magnam Aquarum Colluviem, kc. Paris, 1809; et in Journ. Gen. de Med. tnm. xliii. et xiv.—Scarpa, Sulla Gravid. Susseq. da Ascite, 4c. Trev. 1817. — Duclos, Lond. Med. Repository, vol. xi. p. 515. — C. Maunoir, in Melanges 'de Chirurg. ElrangeVe, kc. t. i. Gen. 1824. — Desormeaux, in Diet, de Med. t. xi. p. 385. — R. Lee, in Lond. Med. Gazette, vol. vii. p. 385. — A. Dugis, in Dirt, de Med. et Chirurg. Prat. t. x. p. 154. VI. Dropsy of the Cellular Tissue,— Syn. Anasarca (from ava, through; and ouo:, the flesh),' i' lonuny.a, Auct. Vet.; ' Araolcnxa, Lossius; Leucophlegmatia, ofCarthuser, and se- veral ofthe older writers; Hydrosarca, Hydrops Anasarca,\uct.; Hydrops Cellularis, M. Good; Die Hautwassersucht, Zellgewebe-wassersucht, Die Wassersucht des Zellegewebe, Germ. ; Anasarque, Fr. ; Anassarca, Ital. 117. Def in. Diffused swelling, pitting beneath the pressure of the fingers, arising from an un- natural accumulation of serous fluid in the cel- lular tissue. 118. Dropsy of the cellular tissue, occurs in various forms and states : 1st. In respect of its form, it may be — (a) partial (CEdema) ; or (b) more or less general, affecting either the tegu- mental cellular tissue chiefly (Anasarca), or the whole cellular substance (Leucophlegmatia). 2d. As to its state, it may be the result of increased action, or of obstructed circulation, or of vascular oppletion (see Cellular Tissue, § 6.) I 6hall, therefore, treat of dropsy of the cellular structure, first, in its partial, and secondly, in its general, forms; and with strict reference 'to the states of vascular action and vital powers. 119. i. Partial cellular Dropsy,— QSde- ma (aSu^a, from oidivi, I swell). A. Limited in- filtration of the cellular tissue is characterised by more or less swelling, which retains the impres- sion of the finger for a short time. It is very common both as a symptom of general debility, or of disease of some adjoining or remote part, or in connection with the dropsical diathesis, of which it may be the earliest manifestation. It often accompanies inflammatory action of the other structures — as the mucous, the fibrous, &c. the contiguous cellular tissue being then infiltrated with serum, owing to its participation in the ex- cited vascular action. Bronchitis, pneumonia, oedema glottidis, rheumatic or gouty affections, are illustrations of this occurrence. In cases of phlegmonous or sthenic inflammation of any part, especially of the cellular tissue itself, or of parenchymatous organs, the parts surrounding its seat are also often cedematous from the same cause. It may also arise from obstructed natural evacuations, as suppressed catamenia, the disappearance of this discharge at the decline of life, constipated bowels, imperfect action of the kidneys, &c. and, in such circumstances, it usually appears in the feet and ancles. It ac- companies several affections of the skin, espe- cially erysipelas; and various structural and malignant diseases, particularly those implicat- ing the venous or lymphatic circulation. It frequently follows the inoculation of animal poisons, as the bites of serpents, &c. ; and it is always attendant upon diffusive inflammation of the cellular tissue, and induration of this structure (see Cellular Tissue, § 9. et seq.). Its dependence upon pressure or disease of the veins, or of the nerves, especially in the puerperal states, has been satisfactorily illustrated by the researches of several modern pathologists, and is fully shown in these articles. It may also arise from extreme fatigue, from exhausted vital powers, the result of previous disease or of old age; it then being generally limited to the lower extremities, and unconnected with any change in the urinary secretion. 120. B. The states of organic action and circu- lation, from which partial cellular dropsy often proceeds, may be resolved into the following : — (a) Increased determination of the circulation, sometimes with diminished power of the ex- halants, the cedematous part being firm, resist- ing pressure, pitting very slightly, and without any diminution, or sometimes with increase of temperature; this constitutes sthenic or active oedema. — (6) Inflammatory action in the nerves of the part, occasioning augmented determination of blood, and effusion of serum, with elevated temperature, and firm swelling, resisting or ad- mitting only of slight and evanescent pitting, and forming an acute or sthenic oedema of rare occurrence.— (c) Obstructed circulation through either the veins or lymphatics, the part being less firm, pitting more easily, and the temperature *4ower than in the former : in this case, the ob- struction may be either internal or external as respects the vessels, or it may exist in the glands; the oedema being either acute or chronic as to its duration, and active or passive, generally the latter, as to its grade of action.— (d) Vascular plethora, or relative increase of the watery parts of the blood, owing to diminished exhalation or elimination by the skin, pulmonary surface, or kidneys, or to the stoppage of accustomed evacu- ations, giving rise generally to sub-acute oedema, chiefly in the feet and ancles.— (e) Diminished tone of the extreme vessels or exhaling pores, attended by a laxity or lessened vital cohesion of the cellular tissue, producing passive or asth- enic oedema, the part being soft, pitting easily and deeply, its temperature very much lowered. Attention to the foregoing pathological conditions and distinguishing characters will readily sug- gest an appropriate treatment (§ 132.). 121. ii. General cellular Dropsy, or Anasarca, affects chiefly the sub-cutaneous cel- lular tissue, usually in a great degree, and very frequently in an acute or sub-acute manner. The cellular tissue throughout the body may possibly become dropsical ; but this must be a very rare occurrence, and manifestly incompa- tible with the duration of life ; although probably it may exist slightly, and constitute the Leuco- phlegmatia of Ccelius Aurelianus, in which he conceives that this tissue resembles wetted bibulous paper, or a charged 6ponge. Indeed, a state nearly approaching to this very general or leucophlegmatia! form sometimes appears in the dark races of the species. The anarsarca described by Mr. W. Hunter, as occurring in Lascars, seems to have been of this kind ; the lungs being especially affected, giving rise to severe and often fatal dyspnoea. Anasarca pre- sents every grade of organic action and duration; and hence it may be divided into the acute or sub-acute or sthenic; and the chronic, passive or asthenic. It may be either primary, as when it proceeds from cold or moisture ; or consecutive, when it follows some one of the exanthemata; 636 DROPSY OF CELLULAR TISSUE —Primary and Consecutive. or symptomatic, when it depends upon obstructed circulation about the heart or other viscera. I shall consider it accordingly. 122. A. Primary acute and sub-acute ana- sarcahas been well described by Stoll, J. P. Frank, Wells, Abercrombie,and others. It commonly occurs from exposure to cold and moist- ure, or from drinking cold fluids, when the body has been perspiring ; and chiefly in the young, or in persons not much past the vigour of life. Oppression and uneasiness of breathing are first complained of; occasionly only tightness about the chest, without cough or pain, is felt; and sometimes cough with pain, aggravated by a full inspiration, and inability to lie down, from in- creased oppression of breathing, are experienced. In a few hours, seldom beyond twenty-four, the dropsical swelling makes its appearance — com- monly i%the face, and descending downwards to the trunk and lower limbs ; sometimes in the legs ; and often in both the face and lower ex- tremities, nearly at the same time. The pulse is either a little accelerated, or of natural frequency; but generally weak or unequal, or even irregular. The urine is scanty, high-coloured, and in some cases coagulable, but in others without traces of albumen. The bowels are usually constipated, and the tongue loaded. There are also headach and thirst. If the effusion be not arrested by treatment, the swelling increases, and respiration becomes more oppressed, or even difficult; and the disease may terminate fatally in a few days, or be protracted to several weeks, or even months. This form of anasarca frequendy attacks indi- viduals belonging to the dark races, upon re- moving to a cold climate, or when the perspiratory functions, which are extremely active in them, are suddenly checked; and is generally attended with extreme dyspnoea, owing to a sub-inflam- matory and cedematous state of the parenchyma of the lungs, which often become affected to the extent of producing asphyxia. 123. The Diagnosis of this variety of anasarca requires attention, as the swelling of the face, and oppression of breathing, with the other symptoms referred to the chest, often existing without fever or acute pain, may cause it to be mistaken for effusion into the pericardium, or into the pleural cavities. But the nature of the affection will be manifest on auscultation. These symptoms generally proceed from active con- gestion of the substance of the lungs, and in some cases from a state of vascular action inter- mediate between congestion and inflammatory action, attended by more or less serous infiltration ofthe parenchyma ofthe organ. That such con- ditions actually exist, to a greater or less extent, when the respiratory functions are disordered, is shown both by the stethoscopic and the rational signs, and by the appearances of inflammatory action or conjestion observed in fatal cases. 124. B. The consecutive form of anasarca was noticed by several writers previously to J. P. Frank, more especially by Stoll and Plenciz. But this celebrated physician first accurately de- scribed it, about 1790, and subsequently his pupil, Grapengiesser and Dr. Wells. Ithas more recently been illustrated by the observations of several writers. It may occur after any of the exanthemata, but most frequently after scar- latina, of which it is rather a common sequela, than a consequence of suppression of either the eruption or the perspiration. It should not, how- ever, be supposed that anasarca is the only form of dropsy that appears after the exanthemata; ascites, or hydrothorax, or even hydrocephalus, may likewise occur, and either of them may be complicated with anasarca. From a number of cases that have come before me, I conclude — (a) that it is dependent on excrementitial plethora, arising out of the suppressed or imperfectly re- stored functions ofthe skin, and other eliminating or depurating organs ; (6) that an incomplete or suppressed eruption will not occasion it, unless the internal secretions and excretions be also im- peded ; (c) that exposure to cold, or to a cold and humid air, or even to humidity alone, will favour its occurrence, although it frequently ap- pears without those aids, and even in very differ- ent states of the atmosphere ; (d) that it is more immediately induced by febrile or generally ex- cited vascular action, arising out of an impeded or interrupted secretion and excretion, and a consequent morbid state ofthe blood (a), and in- crease of its fluid parts, accompanied by deficient power or tone of the extreme vessels and exhaling pores, either absolutely or relatively to the action ofthe heart and arteries. 125. Plenciz describes the anasarca conse- quent upon scarlatina as having been more fatal in Vienna, about the middle of the last century, than the original disease; whilst Dr. Cullen states it to be a mild and manageable affection. Its severity, probably, varies with the state of the pre- vailing epidemic. It is often the most severe when the cutaneous eruption and angina have been slight. There is some difference observed in the period at which it supervenes. Frank often met with it as early as fourteen days from the commencement of the fever ; whilst, in other cases, it has not come on until twenty-eight or thirty-one days from that time. It commonly appears in from sixteen to twenty-four days, and is preceded by slight fever and languor. The sore throat and fever of the primary malady ge- nerally have partially or nearly altogether disap- peared, and the appetite begins to return ; but the bowels continue costive, the urine scanty and high-coloured, and the skin dry and harsh. Slight increase of the fever in the evening, the patient being morose and restless, thirst, and some- times pain about the throat, capricious appetite, and sickness, come on, and are soon followed by oedema of the face, particularly of the eyelids, which is greatest early in the morning, extending rapidly over the body. With this extension of the anasarca, there are often symptoms of vas- cular fulness in the head, the patient becoming somnolent, torpid, and the pulse less frequent In other cases, symptoms of effusion into the peritoneum, or into the pleune, or upon the brain, or of an oedema of the lungs, are superadded, the two latter affections being attended by evidence of danger, occasionally as early as the third or fourth day. As the anasarca becomes general, or thus complicated, or even previously, the urine, which had been long scanty, assumes a still higher colour; is turbid after standing, de- positing slight albuminous flocculi, or resembling whey; is voided frequently, and in very small quantity, and often with pain in the region of the I bladder or in the loins, and vomitings. In some DROPSY OF CELLULAR TISSUE —Asthenic. 637 instances, the urine has a brown appearance, from the presence in it of some of the red particles of the blood. Frank likens it to the washings of flesh, owing to this circumstance. It generally coagulates more or less on the application of the usual re-agents. 126. In the less favourable cases, symptoms of danger appear from the third to the ninth day from the commencement of the oedema of the face; but after twelve or fourteen days, they very seldom occur; convalescence often, under a ju- dicious treatment, having commenced or pro- ceeded far by this time. The danger in this form of anasarca depends upon its complications.— 1st. Upon active congestion, inflammatory action, or serous infiltration of the substance of the lungs, as in the primary form of the disease (§ 122.); dyspnoea, sense of oppression, constriction and anxiety in the chest, with dry cough and inability to lie down supervening, and indicating the nature ofthe complication:—2d. On effusion on the brain, ushered in by headach, sickness, and vomiting; and evinced by dilated pupils, slow pulse, con- vulsions, strabismus, loss of sight, and other signs of acute dropsy of the brain:—3d. On effusion into the pericardium, indicated by swellings ofthe face, neck, and hands, fulness of the veins of the neck, bloated countenance, irregular pulse, leipo- thymia, and fulness and tenderness of the inter- costal spaces, chiefly of the left side :— 4th. On effusion into the pleurae, sometimes also associated with some effusion into the pericardium, and the Bymptoms of hydrothorax :—and, 5th. On disease of one or more of the abdominal viscera, either with or without effusion into the peritoneum; se- vere diarrhoea or dysentery occurring, and, whilst it carries off the dropsy, causing a chronic disease of the digestive mucous surface, occasionally with nlceration and its consequences; or suppression of urine from congestion or inflammation of the kidneys taking place, and aggravating all the dropsical symptoms; or obstruction of the liver superinducing an obstinate and dangerous form of ascites. 127. Anasarca consecutive of scarlatina is most frequent in children, and is rare in adults. Other eruptive diseases, beside this, give rise to dropsy ofthe cellular tissue, especially measles, erysi- pelas, urticaria, miliary fever, and many chronic diseases of the skin; owing not only to their suppression or retrocession, but also to impeded secretion, and to the consequent excrementitial plethora often attendant, or consequent, upon them. When it is consecutive of these diseases, it possesses either the sub-acute character com- mon in that following scarlatina, or the more acute symptoms of the primary form. 128. C. Primary asthenic anasarca is not so fre- quent as the preceding. It is even questionable whether or not the asthenic cases, usually con- sidered as idiopathic, are not depending either on structural change in an important emunc- tory, as the kidneys, or on obstruction about the right side of the heart, or congestion of the large veins and ofthe lungs. There can be little doubt that many of them are thus connected; yet some instances will present themselves, in which the asthenic state is primary, as far as can be ascer- tained. These are most likely to occur in persons living in cold, miasmatous, moist, low, imper- fectly ventilated, and dark places; particularly in those of a lymphatic or phlegmatic temperament, or who lead sedentary lives, and are insufficiently nourished; in those who have experienced copious losses of blood, or are reduced by chronic or re- peated discharges, as by haemorrhagia, diarrhcea, dysentery, &c, or who, whilst convalescent from severe exanthematous or other fevers, have been exposed to cold and humidity; and in persons under the influence of depressing emotions, or who have suffered some sudden alarm. This form of the disease may accompany retention of the menses, or chlorosis; and it may supervene also, in debilitated states ofthe frame, upon obstructions of the catamenial or hemorrhoidal evacuations. Many of such cases, however, will approach very nearly to the sub-acute form, and derive benefit from evacuations. The cases of anasarca produced by terror, disappointment, surprise, mental distress, &c., and termed spasmodic by Landre Beauvais, and some other writers, ap- pear to belong chiefly to this variety. That these and similar causes are sometimes followed by anajf-.rca, cannot be disputed; but I question the dependence of the disease on spasm. Even granting the existence of spasm, what are the parts affected by it, and how does it act ? Con- vulsions will sometimes occasion oedema of cel- lular parts; but they will also, during their continuance, sometimes remove the effusion, as observed by Dr. Wells. The causes which are supposed to act by spasm, merely derange or impede the circulation through the heart and lungs, occasionally also rendering the hepatic circulation more languid or difficult than natural, whilst they lower the vital tone of the extreme vessels, particularly in weak and irritable consti- tutions, and interrupt the excretory functions, thereby inducing the conditions of the vascular system most favourable to the occurrence of serous effusion. Cases rapidly produced by fright have been recorded by Tissot, Desessart, Beauchene, Brkschet, Bateman, and oth- ers; and numerous instances connected with disor- dered or delayed menstruation, and the exhaust*- ing diseases mentioned above, have been adduced by Plater, Riedlin, Forestus Piso, Wil- lis, Eller, Hoffmann, Sauvages, Leib, Melitsch, and later writers. 129. Asthenic anasarca generally appears slowly, and with all the signs of debility and laxity of the soft solids; whilst the sthenic dis- ease often forms rapidly, and with many of the symptoms of fever, or increased action. The infiltration usually commences in the lower ex- tremities; sometimes in the face, or in bolh; slow- ly extends over more or less of the body; and is most remarkable, as well as most early, in those parts of the cellular tissue which are the most lax, as the eyelids, genitals, &c. The pulse is small, soft, and occasionally slow; the skin be- comes paler, whiter, and colder than usual. The surface pits much more easily on pressure, and retains the impression longer, than in the acute or sub-acute forms. At first, the infiltration of the lower extremities is most remarkable at night, and nearly disappears in the morning; but it subsequently returns earlier in the day, and to a greater extent, and is incompletely or partially dispersed by the horizontal posture; the reverse taking place as to the oedema of the face. Ultimately it becomes much more con- 57 638 DROPSY OF CELLULAR TISSUE —Treatment. siderable, more general, and more permanent, sometimes with signs of coincident or consecutive effusion into one or more of the serous cavities. But the collection is very rarely so great, or so complicated, in primary asthenic anasarca as in the symptomatic. The urine is in small quantity, and seldom contains albumen. The bowels are either sluggish or irregular, more commonly the former. 130. D. Symptomatic anasarca may present either acute, sub-acute, or chronic characters. But it is most frequently chronic, passive, and asthenic, and nearly resembles the primary asthenic variety now described, as respects the constitutional powers. When, however, anasarca is complicated with, or consecutive on, acute diseases of the lungs (§ 29.), it is also acute or sub-acute; but it is rather, in this case, a con- comitant effect of the exciting causes of the pulmonary disease, than a symptomatic affec- tion. Organic changes of the heart and kidneys are the most frequent sources of symptomatic anasarca. I shall, therefore, notice this com- plication more closely than the others.— (a) Anasarca generally supervenes on chronic lesions of the heart, and especially towards the close of life; usually commencing in the face, particu- larly in the eyelids, and upon rising in the morning. Sometimes the ancles begin first to swell, and occasionally both the face and ancles— the former in the morning, and the latter in the evening. The infiltration gradually increases and extends; effusion into the pleurae, or into the pericardium, or into both, also taking place either simultaneously or subsequently. 131. (6) Anasarca caused by disease of the kidneys is very seldom seen unassociated with effusion into one or more of the serous cavities. It is, when thus complicated, attended by pain in the loins, by sickness, vomiting and diarrhoea : it usually commences in the lower extremities; and is commonly in consequence of irregular and drunken habits, or of the scrofulous dia- thesis. It is very liable to recur, and is seldom permanently removed (§ 34.). Anasarca is also sometimes a consequence of chronic disease of the lungs, particularly chronic bronchitis, bronchor- rhaa, chronic pleuritis, and tubercular phthisis. In these cases, the infiltration commences either in the face or in the lower extremities, only oc- casionally extends as high as the thighs or hips, and seldom becomes general; but is often asso- ciated with effusion into the cavities of the chest. Organic changes of the liver and uterine organs but rarely occasion anasarca, until after effusion into the cavity of the peritoneum. The ob- servations already offered respecting the con- nection of dropsy with disease of the blood- vessels and lymphatics (§ 27.) are entirely appli- cable to this species of the disease. Although complete obliteration of one even of the largest venous trunks has taken place, serous effusion will not necessarily follow, especially if a col- lateral circulation be established. A remarkable instance of this is recorded by Mr. Wilson, where the vena cava was entirely obstructed, but no vestige of serous effusion existed,— evidently proving that other pathological conditions, beside venous obstruction, are requisite to the occur- rence of effusion; whilst in the case of obliterated cava published bv Laennec, ascites and nnasnrea of the lower limbs existed. Of the agency of disease ofthe vascular systems in causing local or partial anasarca, sufficient notice has been taken ^§ 25. et seq.). The causes, morbid appear- ances, and prognosis, in anasarca, have been de- scribed under these heads in the early part of this article (§8. 14. 37.). 132. iii. Treatment.— 1st. Ofpartialor local Anasarca.— After removing the remote causes (§ 8.), the next object that we have to attain, is to restore the natural secretions and excretions, when any of these are in fault, and to remove the pathological state on which the affection depends. The restoration of the secretions will be attempted by the means appropriate to those chiefly disordered,— by purgatives, diuretics, dia- phoretics, deobstruents, &.c, as the intestinal, the renal, the perspiratory, and the biliary secretions, may indicate more or less of disorder or of inter- ruption. If the oedema depend upon the arthritic or rheumatic diathesis, after the use of these means, colchicum internally, and iodine exter- nally, may be prescribed, and aided by the sup- port of bandages: if it proceed from amenorrhea, or the final disappearance of the catamenia, a moderate bloodletting, general or local, should precede the means directed to act on the secre- tions. In many of such cases, as well as m others where there is no obstruction to the cata- menia, particularly in females who have had children, or who are subject to constipation, and faecal accumulations in the large bowels, the femoral veins are either chronically inflamed, obstructed, or varicose. Their course should, therefore, be carefully examined; and if any hardness or tenderness exist, leeches ought to be applied. In old or chronic cases, however, the veins will either feel hard and obstructed, without much pain, or they will be nearly oblite- rated, the superficial vessels being distended and varicose, and the surface of the limb sometimes purplish or dotted with dark red spots, cold, tumid, and unyielding to the touch; pain and stiffness being referred chiefly to the lower part of the leg and ancle. In several such cases, I have prescribed, with marked benefit, deobstruent purgatives, the sub-borate of soda, and iodine; causing the patient to wear a laced stocking, and to have frequent recourse to frictions. Be- nefit will be derived also from frictions with mercurial liniments, united to one of those about to be referred to; and from a course of bitter aperient medicines. When the disease of the veins is connected with marked debility and weak powers of digestion and assimilation, gentle tonics, chalybeates, frictions with stimulating and deobstruent liniments (§ 65.), will accelerate a cure. (See PhlegmatiaDolens and Veins; — Diseases of.) 133. The connection of oedema with amenor- rhea, independently of obstruction in the veins, requires a persevering internal use of iodine, or of the sub-borate of soda, with tonic aperients, or the compound decoction of aloes, &e, preceded by general or local depletion when signs of ple- thora or internal congestion are present. But when there are a chlorotic appearance of the countenance and surface, or irregular manifest- ations of hysteria, with great mobility ofthe mus- cular, and susceptibility of the nervous, system; a weak, soft, open, or undulating pulse; and DROPSY OF CELLULAR especially if the catamenia have not appeared, or, having imperfectly commenced, have disappeared; the disorder may have been induced or per- petuated by manustupratio, and require from the commencement a tonic and stimulating treatment, and the liberal use of the preparations of iron. When aperients are necessary, the compound de- coction of aloes with the compound mixture of iron ; and the pil. ferri comp. with the aloes and myrrh pill, or with aloes only; are amongst the best. 134. When oedema of the lower limbs depends on the pressure of the gravid uterus, cooling aperients, especially the confection of senna with cream of tartar, small bloodlettings if there be vascular oppletion, a light diet, the recumbent posture, pure air, and patience, are the chief re- medies. When the local anasarca is caused by the pressure of enlarged or diseased glands, mer- curial deobstruents, internally and externally, the preparations of iodine, or the ioduret of mercury, may be used, and the secretions and excretions promoted and duly evacuated by deobstruent purgatives ; or with a combination of tonics and aperients. The taraxacum with the alkaline car- bonates, and either the liquor potassae, or the oxymuriate of mercury in very minute doses, taken in the compound decoction of sarsaparilla, or in the concentrated preparation of Messrs. Savory and Moore, have been of essential ser- vice in several cases in which I have prescribed them. 135. 2d. Of general Anasarca. — A. Of pri- mary acute and sub-acute anasarca, little beyond what has been advanced respecting the treat- ment of acute dropsies (§ 40, 41.) need be here stated. If any difference in the measures is at all admissible, it respects merely a more energetic adoption of depletion, and a greater necessity for repeating it, in this than in any other species of dropsy, especially in its acute states, occurring in young, plethoric, and robust subjects. The in- structive case published by Dr. Graham is an excellent illustration of this practice. When the patient complains of pain in the loins, and the urine is very scanty, or nearly suppressed, general bleeding will often be advantageously followed by cupping on the region of the kidneys. In addition to vascular depletions, the same remedies, espe- cially purgatives or cathartics, directed in nearly the same succession and manner, as described at the places referred to, and at § 55., should be em- ployed ; and lastly, diuretics, associated in the way there advised, may be resorted to. It is ob- vious, however, that the extent to which the anti- phlogistic treatment should be carried, must depend upou the nature of the case, and the acumen of the physician in detecting those latent states of active congestion, or of increased organic action, to which acute dropsies so often are owing. 136. B. In consecutive acute anasarca, appear- ing in the manner described(§124,e/ seq.),a nearly similar treatment to the above, in a less active form, however, in many cases, will be required. The sources of danger in this form ofthe disease, particularly when it follows scarlatina or measles, should always receive attention ; and the remedies ought to be so directed as to prevent their acces- sion. The directions alreadygiven(§ 40.) respect- ing general or local bleedings, should be strictly fol- lowed ; and active counter-irritation and external TISSUE —Treatment. 639 derivation,— as the application of a large blister upon the nape of the neck, or between the shoulders,— be afterwards resorted to, especially if symptoms of cerebral oppression, or of affection of the thoracic organs, manifest themselves. If tenderness on pressure be felt in any part of the parietes ofthe chest or abdomen, or ofthe region of the heart, inflammatory irritation in the pleurae, peritoneum, or pericardium, should be dreaded, and local depletions at some distance from the seat of pain, followed by external irritants and deriv- atives (§ 57.), be prescribed. If sickness and vomiting come on, an inflammatory affection of the head should be suspected, and be treated by active depletion and cathartics. In some cases, however, the vomiting depends upon disease of the kidneys ; attention, therefore, should be paid to this circumstance. When diarrhaa is present, the supervention of ascites, or the existence of lesions of the kidneys, is to be feared. Without suddenly checking this discharge, means should be used to moderate it if it be caused by in- flammatory action, and to evacuate offending matters if it seem to proceed from this cause. Leeches should be applied to the abdomen or its vicinity — to the anus or sacrum, if there be te- nesmus — and be followed by hot fomentations, especially the terebinthinate; and, if the evacua- tions be offensive, scybalous, knotty, &c. a full dose of castor oil, or any other purgative, as calo- mel and jalap, &c. should be taken, and a full effect be promoted by purgative or laxative and emollient enemata. Afterwards digitalis may be exhibited, with liquor ammonias acetatis, infus. taraxaci, and syrupus scillae ; or the ammoniated spirit of colchicum may be given in a similar form. 137. In all cases, of both the primary and consecutive disease, the propriety of acting upon the secretions and excretions should be kept in view. In the former state especially, the cathar- tics, particularly those which act as hydragogues, as elaterium, croton oil, the euphorbia lathyris, and others enumerated above (§ 66.), may be pro- scribed with due caution ; but, in the latter form, the common purgatives, as calomel and jalap, or the infusion of senna with some neutral salt, will be sufficient. The restoration of the cutaneous functions should be a chief object in the treatment of consecutive anasarca. With this intention, tepid bathing in acute cases, when the temperature of the surface is increased; and warm bathing (Aaskow) in the sub-acute ; and the various me- dicated baths already noticed ; may be directed, and be followed by gentle friction of the surface with warm oil, as advised by Schmidtmann ; or with sweet oil, as used by Oliver, &e; or with almond oil. I have adopted this treatment in several cases of anasarca following scarlatina, and seen benefit derived from it. As to the use of diuretics, it is unnecessary to add to what is stated in other places (§ 71.) respecting them. 138. 3d. In Primary Asthenic Anasarca, the prepartions of iodine, the ferrum tartarizatum, with cream of tartar ; the balsams and terebin- thinates ; sulphur ; the association of tonics with purgatives and the warmer diuretics; chaly- beates ; and the rest of the tonic treatment re- commended above (§ 42, 43.); are chiefly to be depended upon. In many cases of this descrip- tion, the preparations of digitalis or of squills may be added to bitter vegetable infusions and 640 DROPSY OF CELLULAR TISSUE —Treatment decoctions, and some one of the neutral salts; and cantharides may be tried, as advised by Chalmers, Alix, &c. The following also may be employed ; the first of which has been re- commended by M. Dumas, the latter by Mr. SfRAGUE : — No. 187. R Antimonii Pulver. gr. xx.; Oroci Martis Aperit. jr. xxv.; Pulv. Scillas gr. xij.; Gum. Ammoniaci Z j.? Extr. Dulcamara- 3 'j- > 0Iei Juniperi q. s. M. Contunde in massam (equalem, et divide in Pilulas Ix., quarum capiat binas vel tres bis terve in die. No. 188. R Decocti Spartii Cacum. (F. 75.) 3x.; Po- tasss Acet. £>ij.; Spirit. .Ether. Nit. ct Spir. Lavand. Comp. aa 3j. M. Fiat Haustus ter in die sumendus. No, 189. R Decoct. Spart. Cac. 3X- : L'l- Ammonise Acetatis jss. j Spirit. Ether. Nit. 3jss. ; Tinct. Scilla; J"-! Tinct. Capsici. Tf) x. M. Fiat Haustus ter die capiendus. 139. 4th. The Symptomatic, Chronic, or Passive states of Anasarca, require the same intentions and means of cure as nave been already stated (§ 44. et seq.), but with a strict reference to the nature of the organic change with which it is connected, as far as that may be ascertained. Anasarca dependent upon disease of the lungs is sometimes benefited by local bloodletting, but the practice requires the utmost discrimination. It is seldom admissible in aged patients; but in the younger and more robust, and when the pul- monary disease consists of active congestion or inflammatory action in the substance ofthe organ, or if the congestion be associated with obstructed circulation through the heart, moderate local de- pletions, repeated in the more acute cases, will be of service: when anasarca follows chronic bronchitis, or tubercular phthisis, it will seldom be productive of benefit, and in the former may be injurious. External derivation, actively and perseveringly employed, is more generally appro- priate. In this form of the disease, the prepa- rations of colchicum or of digitalis cautiously exhibited, and the rest of the treatment directed in the manner described above (§ 49.), will afford more or less relief. 140. When the disease ofthe heart, associated with anasarca, is of an active kind, and the patient is plethoric or robust, local depletions, followed by hydragogue purgatives and digitalis, are re- quisite. But, if it be of a passive or a tonic kind, an opposite practice is indicated. The particular remedies that may be used in these cases have been fully stated (§ 45. et seq.). If the liver be diseased as well as the heart, the prolonged and daily use of deobstruent purgatives (§ 66. etseq.) and diuretics ; the alkaline carbonates, with ex- tract or decoction of taraxacum ; a discriminating use of mercurial purgatives ; calomel with digi- talis, as advised by Wiedemann ; cream of tartar with sulphur and sub-borate of soda, as recom- mended by Piderit ; and the ammoniated pre- paration of colchicum, with the sub-carbonates and bitter infusions, and some diuretic tincture or spirit; will be productive of advantage. When the effusion seems to arise from disease of the kidneys, the treatment already recommended (§ 52.) may be tried. The effects of remedies on the urine, and on the symptoms referrible to the kidneys, ought to be carefully watched. Cream of tartar with borax, the alkalies with the uva ursi, the acetum scillae saturated with potash (Sackenreute r),the balsams with mag- nesia or the carbonates, and external derivatives, or counter-irritation, may be employed. Dr. Ven- ables recommends cupping on the loins, and the insertion of issues in that situation ; and I have seen benefit derived from the practice. But when these organs are manifestly diseased, no perma- nent good effect can be expected from medicine. The connection of anasarca with uterine disease requires but little additional remark. The means already described (§53.) are quite appropriate to this species of dropsy- When, however, hys- teria is present, the more cooling tonics, as the decoction of cinchona with the liquor ammonite acetatis, nitre, and the nitric aether ; or vegetable bitters, with alum and opium, as advised by Leib ; tonic infusions with an alkaline carbonate, nitrate of potash and squills, &c.; will generally be serviceable. 141. The treatment now described will require constant modification, in respect both of the association of different classes of medicines, and in the combination of those possessed of analogous properties — as regards conjoining tonics with purgatives, or various diuretics one with another. The remarks offered above, as to the numerous medicines which have been employed in dropsies (§ 54. et seq.), will assist the practitioner in select- ing from amongst them for the removal of anasarca, whether this species exist simply, or in conjunction with effusion into one or more of the serous cavities. The pyrola umbella, recommended by Dr. Som- erville, and more recently by Dr. BEATTYand Dr. Seymour ; and the liverwort, employed in the manner pointed out by Dr. Shortt, should be duly tried. 142. The propriety of having recourse to sea- rifications and punctures has been much ques- tioned. But it entirely depends upon the circum- stances of the case, and the manner of making them. When the limb is cold, pits deeply, and retains the impression long ; when the patient is old, and, from the irregularity of the pulse, &c, probably has ossified arteries ; and when livid or dark spots appear in the extremities ; scarifications will be attended by much risk of being followed by sloughing sores, although acupuncturation may be substituted with advantage, as recommended and employed successfully by Mr. Churchill. Indeed, this seems to be the preferable mode of at- tempting to evacuate the collected fluid. Dr. Koenig advises the use of electro-puncturation. It is a question whether or not acupuncturation may not be preferable to any other mode of puncturing in this disease. Several practitioners direct small punctures with the point of a lancet, as the safest and best mode of directly evacuating the infiltrated fluid. This practice was praised by COL DE VlLLARS,GuENAULT, ADET,THI- lenius, and some later writers. In several in- stances of sloughing sores consequent upon the rupture ofthe skin, and upon scarification, I have seen the most decided benefit derived from the application of a cloth moistened with spirits of turpentine over them. This medicine causes a rapid subsidence of the swelling, and restores the cohesion of the rarified and weakened tissue surrounding the divided or destroyed parts. Biblioo.andRefEH.—Hippocrates,Tltni rovovir,] .ii. i. 10. — Celsus, 1. iii cap. 21 —Galen, De Locis Affect. 1. v. cap. 7. — Oribasius, vii. r. 35. — Calius Aurelianus, p 470. — At tins, Tetrab. iii. ». ii. cap. 28.—Alexander Tr ,llianus,l. iii. cap. 29. (Bloodletting and ant iph logis- tics.)— Avicenna, Canon. 1. iii. fen. xiv. tr. iv. cap. 14. (Venisection.) — Plater, Observ. I. iii. p. 630. — Willis, Pharmac. Rationalis, pars ii. s. ii. cap. 5. — Lossius, De Languore Lyinphatico AiuOuyxu. Witeh. 1673. — Fo- restus, 1. xix. obs. 25, 26. 35.—Riedlin, Mi lenarius, DROPSY OF THE CHEST —Pathology of. 641 No. 421., et cent. i. obs. 21. (Consequent on measles.)—J. Spon, Aphorismi Novi Hippocr. 1689, p. 392. (Blood-let ting.)—Bonet, Med. Septentrion. I. iii sect. 21. p. 723. ; et Polyalihes, 1. iv. cap. 46. 59. (AntiphlogUtics.) — Col de Villars, Ergo Leucophlegmatia Leves Scarificationes. Paris, 1738.—Guenault, Ergo Leucophl. Leves Scarif. Paris, 1750. —Adet, Ergo Leucopnleematise Leves Scarificationes. Paris, 1758.—Cartheuser, De Leucophlegmatia. Fr. 1760.—Liv- ingston, Edin. Med. and Phys. Essays, vol. ii. p. 4)7.— Plenciz, Act. et Observ. Mil p. 87. 107.—Stoll, Rat. Med. par. iii. p. 302.—Alix, Obs. Chirurg. fasc. i.—S'luvages, Nos. Meth. vol. ii. p. 470.—Thilenius, Med. u. Chirurg. Bemerk. p. 168.—Cheston, Philo». Transac. 1780, p. 323. 578. (Tho- racic duct obliterated.)—Bang, in At. Reg. Med. Soc. Haun. vol. iii. p. 118.—Aaskow, in Ibid. vol. iii. art. 15.— Hartmann, De Anasarca, Lac Sulph. et Acid. Sulph. &c. Fr. 1787.—Dove, in Edin. Med. Comment, vol. xviii. p. 135. —Tozzetti, Raccolta, kc. No. 4. (.Recommends blisters in the an-isarca consequent on scarlatina.)—Tode, Med. Chir. Biblioth. b. v. p. 432.—J. P. Frank, De Cur. Horn. Morbis, I. iii. p. 15—Chnlmers, On the Dis. of South Carolina, vol. ii. p. 20.—Vieusseux, in Journ. de Me I. Contin. t. iii. p. 3. —Leib, in Philad. Transact, vol. i. p. 1.—Marcus, Magazin fur Specielle Therapie, b. ii. p. 342.—Melitsch, in Stark's Archiv. b. iii. p. 724. —Beauchene, in Journ. Gener. de Med. t. xxxii. p. 371. — Windmann, in Hufe'and u. Himly's Journ. d. Pr. Heilk. Oct. 1809.— Sackenreuter, in Allgem. Med. Ann. Mart. 1811, p. 243.—Dessessart, Recueil de Dissert, et Observ. de Mrd. Prat. Paris, 1811.—J^ Wilson, in Trans, of Soc. for Imp. of Med. and Chir. Knowledge, vol. iii. p. 65.—W. C. Wells, in Ibid. p. 167. et 187.—D. C. F. Hartes, De Hydr. Inflammatorio, in Opera Minora, vol. i. p. 339.—Gairdner, Ed. Med. and Surg. Journ. vol. xiv. p. 479.—Steele, in Ibid. vol. xvi. p. 545.—Landre'-Beauvais, Diet, de Med. t. ii. p. 192.—Laennec, Archiv. (iener. de Med. t. vi. p. 619.—Koenig, in Hufeland's Journ. July, 1829.; and Archiv. Gener de Med. t. xxi. p. 449.—Fena- bles, in Lond. Med. Gazette, vol. v. p. 397.—Beatty, in Trans, of As-oc. Phys. of Ireland, vol. iv. p. 23.—J. Bouil- laud, in Diet, de Med. et Chir. Prat. t. ii. p. 320. (See also the Bibliography and References to Dropsies in Genere.) VII. Dropsy of theCavities of the Chest. 143. Defin.—Sense of oppression in the chest; urgent dyspnaa on exercise or in the horizontal posture; livid lips; edematous countenance and extremities; weak, small, and irregular pulse; disturbed sleep, with sudden stortings, 8rc. 144. As dropsy of the pericardium is so very generally connected with more or less effusion into the cavities of the pleura?, that we seldom find the one without the other, although in vary- ing grades and relative proportions; and as the former, as well as the latter, is a very frequent consequence of structural change in the substance of the lungs, or in the pleura?, or in the heart itself and its valves; I shall, therefore, describe them as species of the same genus. The difficulty, also, of determining whether the fluid is chiefly, or altogether, in the pericardium, or in the pleu- ra, even in cases where it is limited to one only, is an additional reason for considering hydro- pericardium and hydrothorax in connection with each other. It is principally, however, when the effusion is symptomatic of structural lesions of the thoracic viscera, or of a more generally morbid state of the frame, that we find them co-existent, and without any remarkable preponderance in favour of either the one or the other. But when effusion is the more immediate result, or the se- quela, of inflammatory action, or of a state of organic action closely allied to inflammation, in either the pericardium or pleura?, it is generally limited accordingly, and it often accumulates to a very great extent. i. Dropsy of the Pericardium.—Syn. Hy- drops Pericardii, Hydro-pericardii, Hydro- pericardia, Hydro-pericardium (from vSwo, water, and niqiy.anllior, pericardium) of Au- thors; Herzbeutelwassersucht, Germ.; Hydro- piricarde, Fr.; Dropsy of the Heart, Eng. 54* 145. Defin.— Oppressive dyspnaa, with a sense of weight and tremor referred to the region ofthe heart; anxiety; inability to retain the supine posture; weak, irregular, or intermitting pulse; livid and cedematous countenance; distension ofthe jugular veins; leipothymia; fulness ofthe epigas- trium, and of the anterior intercostal spaces; per- cussion emitting a dull sound, and auscultation furnishing a faint and diffused sound, over all the cardiac region. 146. A. It is obvious that pathologists ought to agree as to the least quantity of fluid in the peri- cardium that should be considered to constitute dropsy of its cavity. Vesalius states, that it always contains a small quantity of water in health, and that he had observed it in criminals who had been quartered while alive. Lower en- tertains a similar opinion. F. Hoffmann, how- ever, comes to a different conclusion; he having observed no fluid in the pericardium of healthy animals: whilst Littre found some in the ani- mals on which he experimented. Haller be- lieves that tins cavity contains a fluid destined to facilitate the functions of the heart, but gives no opinion as to its quantity, in health. He remarks, that it may be greatly increased in various diseases, and that it may be absorbed (Elementa Physiol. Src. 4to. vol. i. p. 292.). Senac infers that, in the natural state, the pericardium contains no fluid; he having found none in several cases in which this membrane and the heart were both healthy. Co r- visart, Testa, J. P. Frank, Kre ysig, Ber- tin, Louis, Elliotson, Hope, &c. appear to have adopted the opinion of Haller, in consider* ing that this cavity always contains a little fluid; but they differ in some respects as to the amount which should be viewed as constituting dropsy of it. M. Corvisart believes that, when it reach- es six or seven ounces, hydro-pericardium exists. This inference has been adopted by Pinel, Be r- tin, Elliotson, and Hope, who think that this quantity will give rise to symptoms indicating, although with great uncertainty, the seat of ef- fusion; whilst Laennec concludes that double or triple this quantity may not admit of a correct diagnosis. Much, however, will depend upon the rapidity of its collection, and the nature of the pathological states either causing it, or con- nected with it. A larger quantity than that,now named, has sometimes accumulated without hav- ing induced such symptoms as could enable the practitioner to decide as to the exact nature and seat of the disease, particularly when chronic affections of the lungs or heart have accompa- nied it. 147. From one to five or six ounces of fluid are sometimes found in the pericardium, in several maladies either of adjoining or of remote organs, especially in persons who have died of phthisis. This collection, obviously greater — at least, the higher amount — than exists in health, seldom gives rise to specific symptoms, although the larger quantity may occasion much disorder. It may, indeed, form very shortly before death, and may merely be contingent on the changes imme- diately preceding dissolution, particularly when the malady destroys life by asphyxia, or when congestion of the lungs and disorder of the respir- atory actions have been present for a short time previously; and its amount may even be increased subsequently to the fatal issue. When fluid collects 642 DROPSY OF THE CHEST—Pathology of Hydro-pericardium. in the pericardium to an extent obviously consti- tuting dropsy, and calculated, from its influence on the functions of the heart and lungs, to be the chief lesion by which life may be abridged, it will give rise to a certain train of symptoms, ge- nerally indicative of the presence of water within the chest, although not always of its precise situ- ation. The quantity that may admit of detection, in this situation, cannot be stated absolutely. The existence of eight or ten ounces, or even of a smaller quantity, may be ascertained, in some instances; whilst in others, nearly double the amount may not be recognised with precision, as Frank and Laennec have truly contended. 148. B. It is important to know the pathologi- cal states on which effusion of fluid in this situa- tion depends, and the conditions of life and of organisation with which it is connected. These points have been but imperfectly ascertained; but, from some attention I have paid to the subject, I believe that they may be referred to the following: —1st. The effusion may be one of the more im- mediate results of inflammatory action (see Peri- car d i u m— Inflammation of), in some instances; and, in others, a remote sequela of this disease.— a. In this case it generally forms more or less rapidly; may not be attended by any or much effusion or inflammatory appearances in the pleu- ral cavities, although it very frequently is so associated; and it may accumulate to a great extent. The instances referred to by Co r visart, Frank, and others, in which several pounds of fluid were found in the pericardium, seem to have been of this kind. The nature of the disease, in this variety, may generally be inferred with some accuracy, when the effused fluid amounts to more than six or eight ounces,— from ante- cedent symptoms of inflammatory or acute dis- ease referrible to the region of the heart, either previously to, or attending, the effusion; from urgent anxiety at the praecordia, with continued jactitation; from a dull sound being emitted, by percussion, to a greater or less extent over the cardiac region, and a faint and diffused sound being furnished by auscultation; from the mo- tions of the heart being perceptible beyond their ordinary limits, the impulse being undulatory, unequal, and felt at various points; and, when the accumulation is great, from a marked fulness in the epigastric region, occasionally with a vibra- tory pulsation, and with fulness of the anterior intercostal spaces of the left side, or with some degree of external oedema in this situation. In some instances of this form of the disease, these symptoms suddenly supervene, and are attended by orthopncea; small, frequent, irregular, inter- mitting, and weak pulse; syncope or leipothymia, followed by slight fits of obscure palpitations, distension of the jugular veins, bloated livid countenance, and cold extremities.— 6. On dis- section in these cases, marks of inflammation are observed in the pericardium, with thickening and sometimes with lymph adhering to its surface, or floating in the fluid in filaments or in the state of albuminous flocculi. Occasionally the fluid is serous and turbid, resembling whey; or albuminous, or sero-puriform, or nearly puru- lent, or even sanguineous. In these, the rapid effusion of fluid appears to be owing to the sud- den loss of the tone of the extreme capillaries and exhalants; the increased and morbid action ofthe vessels supplying them still continuing, sometimes connected with an unhealthy state of the system. — c. This form of pericardiac dropsy may exist either alone, or it may be complicated with, or consequent upon, pleuritis, or pneumonia, or acute bronchitis; or may be connected with the rheumatic or gouty diathesis, and be even a me- tastasis of these maladies. 149. 2d. Fluid may be effused in the pericar- dium, as in other serous cavities, by a slower pro- cess than that generally accompanying or follow- ing inflammatory action; and be attended by a very different state of this membrane.— a. In this class of cases, the effusion commonly depends upon impeded or disordered circulation through the heart or lungs, arising from a variety of organic changes of a chronic kind in these organs; or upon structural lesions of the pleura; or upon disease seated in the mediastinum, or in the large vessels. It is, in suoh instances, often connected with a leucophlegmatic, lymphatic, or dropsical diathesis, and debilitated frame. The fluid collects slowly, is accompanied by no local or constitutional symptoms of an inflammatory kind; and the attendant disorder is aggravated by an anti-inflammatory treatment. When it reaches a very considerable amount, the patient feels a weight in the cardiac region, with pain in the back and loins: and if he be emaciated or thin, the im- pulse given to the fluid by the dilatations of the heart may be felt and seen between the third and fifth ribs. The sensation of the organ floating in a fluid, said, by some writers, to be felt by the pa- tient, has not been confirmed by my observation; but the feeling communicated to the hand of the physician, by the stethoscope, is frequently that of an impulse transmitted through a fluid, and an undulation is sometimes felt. In addition to these, and the preceding symptoms (§ 148.), there are often a dry cough, leipothymia, some- times followed by palpitation, which is occasion- ally violent; inability to use any exertion; a necessity of sitting up, and of leaning forward; a cold, leucophlegmatic, or cedematous coun- tenance, with lividity of the lips; cold and ana- sarcous extremities; fewness of spirits; emaci- ation, particularly of the trunk; scanty, red, and laterititious urine. Inability to lie in the supine posture is often an early sign; although the patient may lie on either side. But this, like several of the other symptoms, is uncertain; for some persons in health are incapable of re- taining the supine posture even for a short time. The above phenomena are also inconstant, ow- ing to the nature of the primary or co-existent lesions; and, when present, they are often obscured by the more prominent symptoms di- rectly depending upon these lesions.— b. On dissection, the pericardium is not reddened or in- jected ; it is somewhat paler, or whiter, than na- tural — occasionally of even a satiny whiteness; but it is generally opaque, slightly thickened, and sometimes softened, and appearing as having been macerated in the liquid it contained, — an appearance which has been doubted by Laennec The fluid itself is usually colourless and limpid; sometimes of a citron tint, or yellow; and occasionally turbid, of a brownish, or of a greenish hue.— c. This form of the disease is seldom or ever met with unconnected with the lesions already alluded to; and is frequently DROPSY OF THE CHEST — Diagnosis and Causes of Hydro-pericardium. 643 merely a part of a more general effusion of fluid, either into other serous cavities — particularly the pleural—or into the cellular tissue. J. P. Frank could adduce only four cases from authors and his own experience, in which hydro-pericardium was not accompanied by some other change in the membrane or related organs; and even one or more of these might have been thus associated. Whilst this variety of the disease is chronic, and manifestly symptomatic, the preceding is acute, at least in its early stages, but sometimes assum- ing a more chronic and passive character; and, although it cannot be said strictly to be idiopa- thic or primary, it may be viewed as a conse- quence of a morbid state of vascular action not altogether identical with the sthenic inflammation which takes place in a healthy constitution. I have seen several instances of it arising from me- tastasis of rheumatism to the pericardium, occur- ring in weak and unhealthy constitutions. 150. 3d. Fluid may be effused in the peri- cardium in a third form, but seldom to the extent of constituting the principal morbid change. It has been shown that the lesion giving rise to the first variety is chiefly seated in the pericardium, and is nearly allied to, although it is probably sel- dom identical with, the true inflammatory action, or phlogosis, of the internal surface of that membrane; and that the second variety is caused by impeded circulation from organic change of the more immediately related organs, the effusion taking place in a similar manner to other symp- tomatic dropsies. — a. But the variety now about to be described, is an attendant upon a very different and a more universal state of disease; usually comes on not long before death; is a consequence of the generally perverted or alien- ated conditions of life, occasioning deficient vital cohesion of this membrane, and lost tone of the extreme vessels and exhaling pores, in which changes the rest of the organisation more or less participates; and is frequently unattended by any prominent symptom. — 6. It supervenes on the latter stages of some malignant or adynamic diseases, in the course of which the blood be- comes contaminated by morbid matters, either absorbed from without, or generated in some part of the body. Thus, I have observed it in several cases of phlebitis, particularly in ute- rine phlebitis; in the true malignant puerperal fever; and in fatal cases of erysipelas, small-pox, and scarlatina. It likewise takes place after wounds from dissection, and in carcinomatous and some other maladies. In all these, the peri- cardium only participates more or less in a similar alteration taking place in other shut cavities, most frequently in the pleura?, excepting in adynamic puerperal diseases, when the peri- toneum is also the seat of effusion to a much greater extent. — c. On dissection, the tissues are found soft, flabby, easily torn, and of a dirty or dusky hue. In these morbid states, the heart and pericardium participate, but they are not inflamed. The blood is often dark, fluid or semifluid, or grumous; and the liquid effused ia turbid, greenish brown, or brown, or sero-san- guineous, and seldom amounting to more than ten or twelve ounces. — d. In this variety of hydro-pericardium, the characters of the fluid, the state of the textures, and the manifest- ations of life, indicate that the vital cohesion, or the organic contractility, and tone, ofvthe mem- brane, and particularly of the extreme exhaling vessels or pores, are lost; and that the more watery parts of the blood, with a portion of the smaller globules, and even of the colouring par- ticles, are thereby enabled to pass through them. It is evidently one of the ultimate lesions pro- duced by contamination of the circulating fluids, and of the soft solids, in the manner pointed out inthearticlesBLooD(§132—152.),andDisEASE (§148.) (See also Heart, andPERicARDiuM.) 151. C. Diagnosis.— The difficulty of distin- guishing dropsy of the pericardium from that of the pleura? has been insisted on by every writer since Morgagni. This has arisen from the cir- cumstances already alluded to; from the very frequent co-existence of effusion into both these situations; and from the extent to which the symptoms accompanying organic lesions of the lungs, heart, and large vessels, producing the effusion into the pericardium, obscure the phe- nomena caused by it. No opinion, therefore, can be formed from any one symptom; and even that founded on a careful investigation of the history ofthe case, and of the tout ensemble of the phenomena, must still be viewed with some distrust. Early disturbance of the actions of the heart, and irregularity of the pulse; a lesser de- gree of dyspnoea relatively to such disturbance. (Morgagni); the sounds heard on percussion and auscultation; the sensations depending on the motions and impulse of the heart, felt either by the patient or by the examiner, as that of the heart swimming in water (Reimann and Sax- onia), and that of an impulse transmitted through a fluid; a fluctuating tremor (Senac) and ful- ness either felt or seen at the epigastrium and anterior parts of the left intercostal spaces; a sense of weight and oppression in the cardiac region (Lancisi); absence of the fluctuation upon concussion or succussion of the trunk ob- served in hydrothorax (Morgagni); an irre- gularity in the situation of the heart's pulse, it being felt, at different times, in different parts of an extensive circle; oedema, or fulness towards the left side ofthe chest (Corvisart); coldness and oedema of the feet, legs, and hands; and leipothymia and palpitations; have been severally insisted on, and are the signs most to be depended upon; but there is not one of them that is con- stantly present, or, when present, that is caused by hydro-pericardium only. When effusion is limited to the left pleural cavity, as in the cases recorded by Mr. Hrnderson and M. Desault, and in which paracentesis was performed, a correct diagnosis is most difficult. 152. D. Causes. — These have been noticed in the description of the different states of the disease, and are nearly the same as those giving rise to other forms of dropsy. The connection of hydro-pericardium with debility, especially of the vascular system, and with a softened and flabby state of the substance of the heart, is deserving of attention. I have seen it thus related, both in children and grown-up persons of all ages, living in cold, low, and damp places, or cellars, especially after the eruptive fevers and rheumatism; and, according to Testa, it is most frequent in females, particularly after de- livery (§ 150.). In the third form which I have described, it very often supervenes in the 644 DROPSY OF THE CHEST —Prognosis and Treatment of Hydro-pericardiom. last stages of the more fatal diseases of the puerperal state. 153. E. The Prognosis must necessarily be very unfavourable. Yet it should not preclude the having recourse to a protracted treatment, as life may be prolonged by judicious measures perseveringly employed, and a cure may event- ually be effected, particularly when the effusion has been consequent upon inflammatory action, or the metastasis of rheumatism to the peri- cardium. The prognosis should entirely depend upon the form of the disease : it is unfavourable in the first variety I have described; much more so in the second; and the worst in the third. 154. F. Treatment.—(a) The means of cure in the 1st variety should be the same as are ad- vised for inflammation ofthe pericardium, as long as signs of phlogistic action exist. But as soon as this lapses into a passive or an asthenic form, no benefit will result from lowering measures. Ener- getic derivation and external counter-irritation ought then to be directed. In most of such cases, however, unless the vital energies are very greatly reduced, calomel with camphor, and small doses of opium, or the sublimate with sar- saparilla,—the former carried the length of saliva- tion, the latter of affecting the gums,—and a seton, or issue, or open blister, kept discharging over the margin of the left false ribs, will be produc- tive of benefit. Whilst these are being employed, the constitutional powers should be supported; and, if they be much deprassed, medicines of a tonic and astringent operation, with light nu- tritious diet, ought to be prescribed. Care must, however, be taken that inflammatory disorder is subdued in the lungs and pleura, when the effusion into the pericardium is thus complicated, before tonics or stimulants of a heating kind are administered. In such cases, the infusion of roses, with small doses of the sulphate of zinc, and sul- phuric acid, with digitalis, will be found the most appropriate. But the main reliance.must be placed upon external derivation. When the effusion has been consequent upon the metastasis of rheumatism, or of gout, active counter-irritation, the combination of colchicum with camphor or ammonia or with both, the alkaline carbonates or subcarbonates in full doses, and tonic purg- atives, with the rest'of treatment already recom- mended, may be employed. 155. (6) In the 2d variety, or that depending upon organic change in the heart, lungs, or large vessels, but little benefit will be derived from diuretics or, perhaps, from any treatment that can be adopted. I believe that lowering mea- sures, too generally resorted to in cases of this description, will only hasten a fatal issue. Much more advantage will be obtained from means which increase the secretions and excretions— the assimilating and eliminating processes. Very small and frequent doses of blue pill, with a tonic extract, or the soap and opium pill; bitter or tonic infusions and decoctions, with an alka- line subcarbonate, hyoscyamus, and extract of taraxacum; an issue in the side, kept freely and long discharging; and due attention to the de- velopement of vital power, by appropriate medi- cines, diet, and regimen, and a pure air, without heating or exciting the vascular system; are the most to be relied upon. The bowels and biliary secretions ought to be moderately acted on by medicines of a tonic, deobstruent, and laxative operation, which will promote vital power, while they exert a derivative action on these viscera. With this view, diuretics of an analogous kind may be added to the other remedies. The treat- ment of the 3d variety must entirely depend upon the nature of the primary disease, of which it is merely a remote consequence. The indi- cations of cure, in these maladies, and a review of the most efficient measures, will be found in the articles Blood (§ 156. et seq.), and De- bility (§ 37, 38.). 156. (c) Paracentesis pericardii.—The pro- posal of tapping the pericardium, made long since by Riolan and Senac, and sometimes practised, is deserving of notice. It was attempted in the case published by Mr. Henderson, and in one of a similar kind by M. Desaiji.t; the existence of hydro-pericardium having been inferred in both. But it was found, in both instances, that the fluid had been effused into the left pleura, from partial pleuritis, and that the pericardium adhered to the heart. An opening, however, has been made into the pericardium by Larrey, Richerand, and Romero. The last named physician punc- tured the pericardium, and drew off the accumu- lated fluid, in three cases; and in two with success. (See Diet, des Sdences Mid. t. xl. p. 371., and Medico-Chirurgical Review, vol. i. p. 477.) He made an incision between the fifth and sixth ribs (but between the fourth and fifth in a short person), and carried it through the pleura. He then introduced his finger, and, having thereby ascertained the presence of the fluid in the pericardium, he made an opening into it with small crooked scissors; through this the fluid escaped into the left pleural cavity, whence it was discharged by placing the patient in a proper position. By this procedure, if the fluid be in this latter cavity, instead of the peri- cardium, as in the cases of Henderson and Desault, the first opening gives it exit, and nothing further is requisite. The plan of Dr. Romero possesses undoubted advantages, even in this last respect; and he has accordingly practised it in five cases of hydrothorax, and in three successfully. 157. It is evident that this operation can be productive of benefit only in those cases that belong to the first variety, or that consequent on inflammatory action, when effusion fre- quently is limited to the pericardiac cavity. In states of the disease depending upon organic lesions of the adjoining viscera and parts, when the effusion is rarely or never so limited, no advantage can be hoped from an operation. In itself, paracentesis, whether restricted to a sim- ple opening into the thorax, or extended to the pericardium in the manner practised by Dr. Romero, is attended by no greater risk than when it is performed on the abdomen. The chief dangers from it are entirely the same as those pointed out above .(§ 105.), when discussing the propriety of it in this latter situation. The fears of danger from the introduction of the external air causing the collapse of the lungs, is not well founded. If the wound be care- fully closed after a deep expiration, the resi- liency of this organ, and the absorption of the air, will overcome the difficulty. The mischief is occasioned in a different manner, — by the DROPSY OF THE CHEST—Pathology of Hydrothorax. 646 action of the air upon the inflamed or otherwise diseased membrane; and hence the impropriety (and probable cause of failure in several cases) of leaving a canula in the opening, or of introduc- ing a tent sponge. I state this from having seen this practice adopted in cases of paracentesis, and carefully observed the antecedent and consequent states of diseased action. I would, therefore, submit, when the last resource of an operation is attempted, that it should be performed with the utmost precautions against the introduction of the external air; and that the opening should be care- fully and accurately closed, and kept closed, in- stantly upon the discharge of the fluid; and that, instead of preserving an opening for its continued flow, the operation should be repeated when it becomes really necessary. (See Pericardium.) Bibliog. an j Refer.—Galen, De Loc. Af. 1. v.— Bartholin, Anat. Reform. 1. ii p. 252.—Piso, De Sero.is Morb. Observ. et Consil. sect. iii. cap. 2.—Diemerbroeck, Op Omn. 1685, p. 615.—Riolanus, Anthropographia. Paris, 1649. I. vi. cap. 7. (Recommends to tap the pericardium.)— H. Saxonia, Praelect. Pract. pars ii. cap. i. p. 648. ed. Vic. 162).—F. Hoffmann, De Hydr. Pericardii. Halae, 1667.; et Opp. Supp. it. c. 2.— Bonet, Sepulchretum, kc. 1. ii. sect. i. oh. 101., et sect. ii. ob. 15.—Mercker, De Hydrocardia. Ultraj. 1711.—Duverney, Mem. de l'Acad. Rov. des Scien. 1703, p. 153.—Senac, Traits de la Struct, et'des les Mala- dies du Coeur, 4to. Paris, 1749. t. ii. 1. iv. cap. 6.—Manget, Theat. Anat. vol. ii. p. 1727.—Lancisi, De Motu Cordis et Aneur. Roma;, 1728.—Morgagni, De Caus. kc. epist. xvi. art. -0., also epist. xviii. xxiii. xxxvi. xxxvii.—Meckel, in Mem. de l'Acad. des Scien. A Berlin, 1755, p. 56.—Lentin, Beytrage, b. ii. p. 61. (Recommends purgatives, diuretics, and stimulants.)—Lieutaud, Hist. Anat. Me I. 1. ii. observ. 611. 621. 648. 663. 683. 857__Borsieri, Institut. Med. Pract. vol. iv. cap. 5.—Sidren, in Act. Med. Suecicorum, t. i. p. 407. (Effus. in pericard. only.)—Sandifort. Observ. Anat. Pract. vol. i. p. 40., vol. iv. p. 109.-^7. P. Frank, De Cu- rand. Horn. Morbis, vol. v. p. 241.—Quarin, Animad. in Morb (hron. p. 99.—Heincke, De Hydr. Pericardii, 8vo. Erf. 1799.— Portal, Anat. Medicale, t. iii. p. 11.—Conradi, in Arnemunn's Magazin, b. i. p. 81. (Advises paracentesis.) —Landvoight, De Hvdr. Pericardii dignoscendo. Halae, 1718.—Desault, (Euvfes Chirurg. kc. t. ii. p. 304.— Corvi- sart. Traite des Mai. du Coeur, &c. Paris, 1818, ed. 3d.— Testa, Uelle Malattie del Cuore, kc. vol. iii. Bol. 1811.— Kreysig, Die Krankheiten d. Herzens, kc. b. iii. Berlin, 1K17.—Wood, iu Lond. Med. and Phys. Journ. vol. Ixi p. 406. (Two quarts of fluid effused.) — Hennen, in Edin. Med. and Sure. Journ. vol. xvi. p. 539. (Effus. into pert- card, only.)—Henderson, in Djid. p. 535. —Laennec, Aus- cult. Med. t. ii. p. 670. 2d edit.; et Translat. by Forbes, p. 67S.—Hard, in Diet, des Sciences Mid. t. xxii. p. 322.— Merat, in Ibid. t. xl. p. 37-1.—Romero, in Ibid. p. 371.— J. Frank, Praxeos Medicae Univers. Praecep. vol. ii. pars ii. se t. ii. p. 168.—Rayer, in Diet, de Mid. t. xi. p. 394.— J. Bouillaud, Diet, de Med. et Chir. Prat. t. x. p. 157.— Bfrtin, Traiti des Mai. du Coeur, kc. 8vo. Paris, 1824.— Portal, Observ. sur la Nat. et sur he Traitement de l'Hydr. t. ii. p. 131. ii. Dropsy of the Pleural Cavities.— Syn. Hydrothorax (vdv>Q, water; -frwoa:, the chest), Hydrops Saccorum Pleura, Auct. var.; Dropsy of the Pleura; Hydropisie de la Poi- trine, Fr.; Brustwassersucht, Germ.; Idropisia di Petto, Ital.; Water in the Chest. 158. Defin.—Dyspnaa and oppression in the chest, increased by the horizontal posture and exerase, with adema commencing in the eyelids and ancles; stortings from sleep; the sounds on percussion being dull, and the respiratory mur- mur not heard on auscultation. 159. Hydrothorax has been divided into idio- pathic or primary, and symptomatic. It is very rarely primary, as M. Laennec has observed — that is, without pre-existing disease of the pleura?, lungs, heart, or large vessels. But it is often consecutive of increased vascular action, or in- flammatory irritation of the pleura?, without any lesion of other parts, particularly when it follows the eruptive fevers ; and it may be a termination of pleuritis, especially in the lymphatic or phleg- matic temperament, and in the cachectic habit of body. Its symptomatic or complicated states are the most common. As the consecutive hy- drothorax, in all its forms, is generally acute or sub-acute, or possesses more or less of the sthenic characters, it will be considered as such ; whilst the symptomatic will be viewed as a passive, chronic, or asthenic disease. 160. A. Acute and sub-acute Hydrotho- rax; Inflammatory Hydrothorax, Hydro-pleuri- tis, or Hydro-pleurisy, of Rayer.—That this form of pleural dropsy consists of increased exhala- tion from the pleura?, depending upon increased vascular action and determination to this surface, will be admitted ; but that it is identical with inflammation, of an acute and healthy kind, may be questioned. The symptoms, local and con- stitutional, in hydrothorax of the most acute kind, and in pleuritis — either the pulmonary or costal — are certainly not identical, particularly in respect of severity. Hence, although much similarity exists, as far as mere vascular injec- tion, or determination of the circulation, is con- cerned ; and although pleurisy may terminate in, or give rise to, serous effusion in many in- stances; yet the kind of organic action affecting the pleura?, and the attendant constitutional dis- turbance, are not the same in both. The differ- ence has already been alluded to (§ 18.); but I may here add, that the formative processes — the kind and grade of organic vascular action — cha- racterising pleuritis, are not observed either in the local lesions or in the constitutional affection of acute hydrothorax, unless when the effusion supervenes on external injuries and inflamma- tion, or is an earlier attendant on a modified condition of such disease. The consecutive states of acute pleural dropsy, as it may be studied after scarlatina, either during life, or in the mor- bid appearances, illustrate this view, and prove, that there is, as respects both the conditions of the effused fluid, and the changes in the pleura?, a difference in the kind of organic action whence they have proceeded, from true inflammation, and that such difference is evidently connected with constitutional causes. It is very common to observe that, when an attack or attacks of either pneumonia or pleuritis have been re- moved by treatment, a slight exposure to their exciting causes, or irregularities on the part of the patient, before the diseased vessels have re- gained their healthy tone and action, will give rise to a less acute, or a smothering, state of dis- ease, either attended by, or quickly terminating in, effusion ; the reduced powers of the constitu- tion, the lost tone of the exhaling pores, and the general or local excited action, favouring this par- ticular malady — this morbidly increased serous exhalation — in preference to any other. In this way acute or sub-acute hydrothorax super- venes on a state of the frame which has not recovered from previous disease — more particu- larly from eruptive fevers — or which has been j impaired by age, excesses, or irregularities ; the powers of life, and the organic action thereon depending, being insufficient to develope sthenic or phlogistic inflammation. The inferences, then, from the causes, accession, phenomena, and con- | comitant changes observed in the acute or sub- 646 DROPSY OF THE CHEST—Diagnosis of Hydrothorax. acute disease, are, that it is not identical with healthy inflammation, although frequently so nearly allied to it as to appear either as a ter- mination, or as a lower grade, or as a modification of it; and that it is often connected with, even although it may not be dependent upon, the nature of the preceding malady, in which the secretions and excretions have been interrupted, and not sufficiently restored. 161. That inflammation of the bronchi, or of the substance of the lungs, will sometimes be propagated to the pleura?, generally in conse- quence of constitutional fault or injudicious ma- nagement, and give rise to effusion into then- cavities, is well known ; that inflammation ofthe surface ofthe liver, or of the peritoneum, or of both, will occasionally extend to the pleura?, par- ticularly in debilitated or cachectic subjects, and, having reached this situation, terminate in effu- sion, I have often remarked ; and that the state of vascular action, whose similarity or connection with true inflammation has been noticed, but whose identity with it has been denied, will occur in the pleurae in various states of sequence and of complication, has been a matter of daily observ- ation, and may be readily illustrated from the pages of Bonet, Morgagni, Stoll, Lepois, Lieu- taud, Leroux, and many other of the writers referred to. In some, localities, also, and during certain epidemics, it has been remarked that perip- neumony has evinced a remarkable tendency to terminate in this manner. Dr. Romero states, that, on the coast of Andalusia, hydrothorax and hydro-pericardium are endemic, owing chiefly to the prevalence of hot and humid winds, and sud- den atmospheric vicissitudes, particularly among those who are ill fed, or live on unwholesome food, and are given to intoxication or irregularities ; and M. Pariset observed this form of hydro- thorax prevalent in Geneva, in 1803, — the symp- toms being so slight that the patient's appetite and ability of attending to his affairs continued until the pleural collection induced violent oppression. He states, that the number who died among the French conscripts was very considerable,—the effused fluid being limpid and inodorous, and the pleura grayish and thickened, and the lung com- pressed, or condensed. 162. The morbid appearances in the acute form of hydrothorax, whether it has been connected with inflammation, or active congestion of the substance of the lungs ; or has proceeded from a modified form of pleuritis, either occurring pri- marily, or consecutively on an eruptive fever, or after the suppression of some chronic disease of the skin, or of an accustomed discharge ; are usually the following : —The fluid presents every shade of colour already remarked (§ 11.)—is sometimes turbid, muddy, reddish, sanguineous, whey-like, or sero-purulent ; but more frequently transparent, of a citron tint, with filaments or numerous albuminous flocculi floating in it. The membrane is internally reddened, or injected, thickened and somewhat softened, and occasion- ally covered by an albuminous, granulated, or. tuberculous exudation. The lungs are generally compressed, condensed hepatised, or tubercu- lated ; and present appearances of chronic inflam- mation. The causes of this form of hydrothorax are the same as those described above (§8,9. 19.) 163. B.Symptomatic, passive, or compli- cated Hydrothorax.—This state of disease is dependent upon some obstacle to the circulation of the blood, or lymph. Its connection with dilata- tion ofthe cavities; with hypertrophy, atrophy, &c. ofthe substance, and with alterations of the valves, &c. of the heart; has been long since pointed out by Bonet, Morgagni, Lieutaud, Meckel, Sandifort, &c. Disproportion between the ca- pacities of the cavities, ossification of the valves, and various other lesions of this organ, have been still more minutely examined in relation to the pro- duction of hydrothorax, by Corvisart, Laen- nec, Testa, Kreysig, Bertin, and others. Varicose dilatation, also, ofthe veins of the lungs, and compression or obliteration of them, from chronic pneumonia, or tubercular and other pro- ductions, are sometimes the immediate causes of effusion. The dependence of this form of the disease upon alterations of the lymphatics, either in their glands or in their trunks, once so strongly insisted upon by the able pathologists already named in connection with this doctrine (§ 27.), although not improbable, has not been established so as to admit it otherwise than as an occasional, and by no means frequent, occurrence. 164. The fluid effused in this form of hydro- thorax is commonly transparent, colourless, or of a citron tint; in rarer cases, it is of a light brown, or reddish hue, or even sanguineous; its quantity varying from a few ounces to ten or twelve pounds, in both the cavities. In some cases, a quantity of aeriform fluid is also present. (See art. Pleura.) On the evacuation ofthe serum, the pleura? are generally observed to be sound; or merely paler, or somewhat softer, than natural. When the accumulation has been great, the lungs are generally pushed up to the vertebral column, are hardly crepitous, and are occasion- ally pale as if macerated; but they sometimes admit of being distended by insufflation, when they have not been inflamed and hepatised. In this form ofthe disease, effusion frequently takes place into the pericardium, as a coexistent result of the same organic changes; and occasionally some fluid is also found in the abdomen, or even within the head; but more commonly in the cel- lular tissue, constituting a more or less complicat- ed or general state of dropsy. M. Rayer justly remarks, that anasarca, hydro-pericardium, and ascites, are more frequently associated with hy- drothorax when it is caused by organic lesions of the heart, that when it is consequent upon altera- tions of the lungs. 165. C. Diagnosis.—As hydrothorax is gene- rally produced by anterior disease, it follows, that it will not become manifest until some days, or even some weeks or months, afterwards; or, in cases of organic change of the heart or lungs, not until a few days or weeks previously to death. Even with the aid of percussion and auscultation, small collections of fluid are ascertained with much difficulty, and are marked by the symptoms of the lesions that cause them. But when the ac- cumulation is considerable, it is generally evinced by phenomena which are proper to it. The patient feels an oppression and difficulty of breathing, great in proportion to its quantity. He generally lies upon the affected side, leaving the healthy one unincumbered in its functions. When the fluid is in both cavities, the respiration is still more difficult and short; the patient, sits up in bed, and DROPSY OF THE CHEST —Diagnosis of Hydrothorax. 647 calls in the aid of all the muscles of inspiration: his countenance assumes a cast of anxiety. Cor- visart describes the chest as being more distend- ed, and rounded on the side which contains the fluid; and, as the collection increases, the intercos- tal spaces are widened; the integuments of this side becoming cedematous, and, in a few instances, the arm on the same side. On percussion a dull sound is emitted, resembling that produced by striking the thigh on the side containing the fluid, or on both sides when effusion has taken place in both. When the patient sits, or stands up, and the fluid only partially fills the cavities, the lower part of the thorax only will give out a dead sound. This sound generally changes its place with the change of position, owing to the gravitation of the water to the depending part. This, as M. Piorry con- tends, is an important diagnostic between the dead sound of effusion and that produced by hepatisa- tion of the substance of the lung, which always retains the same situation. In the acute states of the disease, a feeling of soreness, tenderness, or pain, is often complained of in or over the seat of effusion. 166. Upon auscultation, the respiratory mur- mur is found to have ceased in the region corres- ponding to the fluid collection; and in its place is heard the tubular or bronchial respiration. In some cases a?gophony is heard when the effusion is not very great. If the fluid be accumulated only in one cavity, mensuration of the thorax then becomes a useful mode of diagnosis; but the increased fulness of one side, and widening of the intercostal spaces already noticed, may be recognised at sight. When the collection is very great in one side, not only is the lung compressed, but the diaphragm and liver are pressed down- wards; and, if it be in the left side, the heart is pushed towards the right. Succussion of the trunk cannot furnish any information, unless air accompany the effusion, in which case fluctuation may be distinctly heard. (See Empyema, and Pleura.) 167. Passive hydrothorax, in itself, frequently occasions but little general disturbance, the func- tions of respiration being only mechanically dis- ordered by it, unless it exist to a very great de- gree. The lesions of which it is the consequence j are the chief causes of both the constitutional de- rangement, and the disorders of the respiratory and circulating functions; and, upon the nature of these lesions, the ultimate result more inti- mately depends, than upon the effusion itself The great diversity of the primary alterations — whether seated in the lungs, or in the heart and large vessels — is the chief cause of the very great differences remarked in the symptoms and progress of the malady. It becomes, therefore, important to ascertain the nature and seat of these alterations — the true extent of assodated disease — on account of the diagnosis, and of the indications of cure. The early history ofthe case, and the immediately antecedent states of disorder, are among our guides in this inquiry. The in- vestigation of these should, therefore, not be over- looked. 168. (a.) When the effusion has been conse- quent upon pneumonia, active congestion of the lungs, pleuro-pneumony, phthisis, or bronchitis, the oppression and dyspnoea, characterising the effusion, supervene without the irregularity of the pulse and palpitations attending the cardiac complication. Either in addition to the symp- toms of these diseases, or at an indefinite time from their partial or apparently total disappear- ance, the dyspnoea increases, particularly upon exertion; the patient requires his shoulders and head to be more elevated in bed than usual, and oedema is observed in his eyelids and feet. In this class of cases, the effusion is generally not very great, nor are the cadema and lividity of the countenance remarkable; but he is unable to lie on the side opposite to the effusion, which is most frequently limited to, or at least in greatest quantity in, one cavity; and ultimately he is of- ten unable to lie down in any position. A fatal termination is commonly slow, and attributable more to the alterations of the lungs, which have been increasing with the effusion, than to the ef- fusion itself. 169. (b.) When the accumulation of fluid has arisen from organic change about the heart and large vessels, the oppression and dyspnoea at- tending it are associated with irregularity and intermissions of the pulse, with leipothymia, pal- pitations; very disturbed sleep, sudden starlings, and frightful dreams; a livid and cedematous countenance, sometimes anasarca; and sinking of the vital energies. The patient can often lie upon the side most affected, but, more commonly, there is fluid in both cavities, and sometimes in the pericardium also. When it is confined to both sacs of the pleura, he often lies upon his back; but, if all the thoracic cavities be affected, he sits up, leans forward, and brings all the re- spiratory muscles into action. The quantity of fluid collected is usually greatest in this class of cases; and a fatal issue, although frequently de- layed or prevented for a longer or shorter time, is more apt to occur suddenly, particularly in fat or plethoric persons. But, occasionally, before this event takes place, the organic lesions of the heart superinduce congestions of the lungs, or brain, which may accelerate dissolution. Also, if, in either of these classes of cases, any important emunctory ceases to perform its functions, more especially the kidneys, whether from functional or organic change, the effused fluid may excite a low grade of inflammatory irritation or action in the pleura, giving rise to a modification of the effusion itself, as well as to some of the changes observed in the pleura and lungs after death, and which have been too generally viewed as the ori- ginal disease, instead of being considered a con- secutive and contingent occurrence. As to the state of the excretions in hydrothorax, they are generally either impeded or disordered. The urine is very different in different cases; in the acute and sub-acute forms, it is commonly scanty, high coloured, or deposits a thick lateritious sedi- ment, and often contains albumen, particularly when it is consecutive of eruptive diseases and suppressed evacuations, or associated with acute disease of the lungs. But in the passive and chronic cases, it is often not materially diminished, and is seldom coagulable unless the kidneys be- come diseased. It should not be overlooked, that the primary lesions in hydrothorax are generally and often necessarily progressive; and that to this circumstance, as well as to the increase of the ef- fusion, the exasperation of the symptoms and its fatal issue are to be imputed. (See also § 29, 30.) 648 DROPSY OF THE CHEST —Prognosis and Treatment of Hydrothorax. 170. D. Prognosis.—The complicated nature of this malady, the advanced stages of the organic lesions producing it at which it supervenes, and the age and habits of those among whom it is commonly observed, will always influence the practitioner to give an unfavorable opinion of the ultimate issue, although the results of repeated ob- servation will induce him to inspire hopes of afford- ing great relief. But every return of the effusion diminishes the chance of even partial restoration. His opinion, also, will be founded on the nature and extent of the primary lesions, either of the lungs, or of the heart, &c, as made manifest by the auscultatory and rational signs. In every case, however, the prognosis should be guarded; for, under circumstances apparently favourable, an unexpected change may occur from the pa- tient's conduct, or the progressive changes in the seat of disease : and his friends ought to be in- formed that, even in a state of no very apparent danger, he may be suddenly cut off. 171. ^.Treatment.—The principles of treat- ment so fully described in the early part of this article are applicable to hydrothorax. In the acute and sub-acute states, bleeding, general or local — more frequently the latter — is required; but it must be practised with caution. The results of experience will confirm the inference at which I arrived above, that, notwithstanding the close re- semblance of the morbid appearances, in acute hydrothorax, to those of true inflammation, yet vascular depletions are not nearly so well borne in the former as in the latter, evidently owing to the differences, particularly constitutional, on which I insisted. But the extent to which it should be carried, and mode of practising it, must entirely depend upon the nature of the original lesion, and the state of vital energy and vascular action. Generally, when the lungs are acutely affected, and their substance congested, or when the lesion of the heart is of an acute kind, as active enlargement of its cavities, moderate de- pletion is both requisite and beneficial. But in the more passive states ofthe malady, our reliance must be placed on digitalis, and other diuretics, with tonics, &c. In many instances, where de- pletion — especially local—is obviously indicated, the propriety of supporting vital power, even at the time of unloading the vessels, or immediately afterwards, by the exhibition of gentle tonics and diuretics, cannot be disputed, more especially when Xhe vascular fulness, or morbid action, is secondary merely, and the consequence either of an excrementitial plethora,—in which cases, pur- gatives, and other medicines calculated to act upon the emunctories, should be also employed, — or of the irritation produced by the properties of the retained fluid. General bleeding is but seldom requisite in hydrothorax; for a sufficient quantity of blood may be taken by cupping, which possesses the advantage of producing a revulsive or derivative action. On this account, I have prescribed dry cupping, where the abstrac- tion of blood was not indicated. In cases where congestion is superinduced in the lungs, or where haemoptysis occurs, cupping, or even dry cupping, is a most important part of the treatment, assisted by digitalis, acids, and external counter irritation. 172. Revulsants are generally of great benefit, conjoined with antiphlogistic and diuretic reme- dies, in acute, and with tonics, &c. in passive, hydrothorax. Setons, or issues, near the margin of the false ribs, on one or both sides, are among the best modes of fulfilling this intention. We k dt advises them to be inserted in the chest; and Autenreith directs a blister over the sternum to be kept constantly discharging. Cathartics, and purgatives, especially the hydragogues, above enumerated, often afford speedy relief; but they are admissible only when the powers of life are not greatly reduced, and in the more acute cases. Diuretics are more certainly beneficial in this spe- cies of dropsy than in any other; and of this class digitalis is the most efficacious, particularly in the form of infusion, and when combined in the man- ner already shown. The praises bestowed on it by Lentin, Withering, Darwin, Hamil- ton, Frank, Maclean, Percival,and many others, have been generally acknowledged to be just. Squills, rank next in utility; but they are not always appropriate, and are even injurious in some of the more acute states of complication, partic- ularly in that with pneumonia or hydro-pleuritis. Senega and ammoniacum, and the tethers, may be used in the passive form of the disease. The propriety of exhibiting diuretics, with tonic infu- sions, and with antispasmodics, as already advised, is especially evinced in the more passive con- ditions of this disease. Camphor, ammonia, and the aethers, particularly the spirit. a?theris nitrici, and spir. a?theris sulphur., are of great utility, when thus associated, or when given with purgatives and tonics. The importance of supporting the constitutional powers, in all the more passive states ofthe cardiac complication, cannot be too highly estimated. In such cases, purgatives should be given only in combination with tonics and antispasmodics; and digitalis will be best ex- hibited in a similar manner. Formulas 400. 516. 781. 856. 859. 893, 894., and the following, as well as other diuretic preparations in the Appen- dix, exemplify some of the foregoing combina- tions : — No. 190. R Hydrarg. Submur. gr. j.; Pulv. Digitalis gr. j.— ii.; Zinci Oxydi gr. iij.; Pulv. Opii Puri gr. ss.: Syrup. Tolutan. q. s. Fiant Pilulae ij., bis terve quotidie sumendae. (HUFELAND.) No. 191. R Tinct. Digitalis TT|x. —xvj.; Tinct. Ca- lumb* 3 jss. ; Spirit. jEther. Sulphur. 3 '»• > Tinct. Opii TT|v. ; Mist. Camphorae 3 *j- M. Fiat Haustus bis quo- tidie- sumendus. No. 192. R Pulv. Scilla; gr. j.; Potassae Nitratis gr. vj. — x.; Sodae Sub-carbon, exsic. gr. viij.; Sacchar. Purif. 5 ss.; Olei Anisi TT{ iij. Tere bene simul, et fiat Pulvis ter in die capiendus. (Selle.) No. 193. R Potassae Sub-carbon. 3 jss.; Potassae Ni- tratis 3 ss.; Tinct. Colchici 3 iij. i Tinct. Aurautii Comp. 3 iij.; Infus. Junip. § vij. Misce. Capiat Coch. ij. vel iij. larga quartis horis. When, in addition to diminished tone of the capillaries, the disease is complicated with atonic bronchitis and mucous expectoration, the first of the following recipes may be administered; and when it is associated with torpor of the liver, the latter may be exhibited :— No. 194. R Pulv. Scillw exsic. gr. xij. -, Pulv. Fol. Di- gitalis gr. xvj.; Hydrarg. Submur. gr. vj. ; Pulv. Gum. Myrrhae 3 »•• '■ tere bene simul, et adde Assaefostidae 3 •»• i et Syrup, q. s. Fiant Pilulae xxiv., quarum capi.it unam quater in die, vel duas mane nocteque. No. 195. K Gum. Ammoniaci, Saponis Venet., aa t) > ' Pulv. Scilla- exsic. gr. x. -, Pilul. Hydrarg. gr. xv.; Olei Juniperi TT) v ; Extr. Taraxaci 3 j. Fiat uiassa aequalis, quam divide in Pilulas xxx. Sumantur dux bis terve quotidie. 173. Paracentesis thoracis, once so strenuously advised, has now fallen into disuse, and is seldom DROPSY, CONGENITAL—Pathology of. 649 or never resorted to, excepting in empyema. In some states of the acute disease, especially when the effusion is principally in one cavity, and is not attended by organic changes in the lungs or heart, of a necessarily fatal or dangerous kind, the con- dition of the patient in other respects not contra- indicating the propriety of performing it, this operation may be as safely and beneficially prac- tised on the thorax as on the abdomen; the same risks — and no greater — existing in respect of the one as of the other. It has been recommended by Goula, Duverney, Bianchi, Delaporte, Morf.land, Huetter, Morand, Lullier, J. P. Frank, Mursinna, Bell, Romero, and Archer, and practised successfully by nearly all of them. The chief danger proceeds from the introduction and action of the air ; but not so much from its preventing the dilatation of the lungs, as from its action on the diseased pleura, and the fluid effused from it, as shown above (§ 157.). (See arts. Lungs, and Pleura.) BlBLIOQ. and REFER.—Goula, Ergo in Thoracis quam in Abdom. Hydr. Paracentesis tutior. Paris, 1624.—Batloni- us, Opera, vol. i. p. 13.—Bartholin, Hist. Anat. vol. ii. p. 7. 66.—Riverius, obs. i. 60.—Willis, Pharmac. Rat. ii. i. 13.— Duverney, in Mem. de l'Acad. Roy. de Scien. de Paris, 1703, p. 197. (Paracentesis.)—Bonet, Sepulchret. 1. ii. s. i. obs. 72. 84., s. ii. ob. 75. etseq.—Bianchi, Histor. Hepat. i. p. 662.—Morgagni, De Sed. et Caus. ep. x. a. 11., cp. xvi. a. 2—iO.—Berger, Sur l'Hydr. de la Poitrine. Paris, 1736. (Paracentesis recommended.)—Bovillet, Sur l'Hydr. de la Poitrine, kc. Bes. 4to. 175J.—Mirand, in Mem. de l'Acad. dc Chirurg. t. ii. p. 547.—Avenbrugger, Invent. Novum ex Percussione Thoracis ut Signo, intern. Morbi 1'ect. detegen- di. Viad. 1761— Moreland, in Philos. Trans. 1766, p. 302. —Sauvages, Nos. Miih. t. i. p. 688.—Ganter, De Diagnosi Morb. Pect. Vien. 1764.—Alston, Edin. Med. Essays, vol. v. part ii. p. 609.—Simson, in Ibid. p. 623.—Lieutaud, Hist. An it. Med. 1. ii. ob. 857. 875.—Delaporte, Ergo Hy- dropi Pectoris Paracentesis. Paris, 1774.—De Haen, Rat. Med. pars v. c. 3., pars vi. c. 4., pars ix. c. 12.—Stoll, Rat. Med. pars i. p. 236. (12 lbs. in the left pleura.), et pars ii. p. 378., pars iii. p. 55., pars vii. p. 216.; et Prselect. vol. i. p. 80.—Vallisneri, 0|>era, iii. p. 185. 526.—Selle, N. B.y- tragr-, b. i. p. 121.—Richter, in Comment. Soc. Goet. vol. ii. (Complicated with carcinoma mamma.) — Boehmer, De Hydr. Pectoris. Hal. 1784.—Hutter, Observ. Med. No. 35. (Cured b,/ paracent.), et No. 34.—Leltsom, in Mem. of Med. Soc. of Lond. vol. i.—Knebel, De Hydrothorace, 4to. Witt. 1795.—Piderit, Praciische Annal. st. i. p. 46.—Reil, Memor. Clinic fasc. iv. No. 3.—J. P. Frank, Interp. Clinic, i. p.118. (18 pints of water.); et Act. Inst. Clin. Viln. Ann. ii. p. 266.—Darwin, Zoonomia, vl ii.—Harles, Opera Minora Acad. vol. i. p. 3 3. 8vo. 1815. (Hydrothorax phlogisticus.) —A. G. Richter, Die Specielle Therapie, t. iii. p. 199.— Wendt, Annal. des Klin. Instit. heft. i. p. 64. (Squills with tartar, iron and arom.)—Autenrieth, Observat. in Hydro- thoracem, kc. Tub. 1809.—Spangenberg, in Horn's Archiv. 1809, p. 40.—Dupuy, in Journ. Gener. de Mid. t. xxxiii. p. 19. (Digitalis with assafcetida and squills.)—Blum, De Hydr. Pectoris. Wurc. 1806.—Larrey, in Mem. de la Soc. Med. d'Emulation, t. vi. p. 354. (16 pints of water.)—Lul- lier, in Journ. de Med. Contin. t. xvii. p. 221. (Paracentecis.) —Mursinna, Journ. f. d. Chirur. b. vi. st. 2. p. 6. 10.—L. Maclean, On ihe Nat. Causes, and Cure of Hydrothorax, 8vo. Ludb. 1810 —Rev. in Edin. Med. Journ. vol. vi. p. 474. —Robertson, in Ibid. vol. x. p. 295.—Hall, in Ibid. vol. viii. p. 303.—Henderson, in Ibid. vol. xvi. p. 529.—Hamilton, On the Prepar. and Administration of Digitalis, Sic. Lon I. 8vo. 1810.—Hufeland, in Journ. der Pract. Heilk. May, 1312, p. 24. (Calomel with oxide of zinc and opium.)—Hard, in Diet, des Sciences Med. t. xxii. p. 489.—Brosius, in Journ. des Prog. t. xvii. p. 260. (Digitalis and lactucarium in large and frequent doses.)—Laennec, On Dis. of the Chest. Transl. 3d ed. p. 491.—Leroux, Cours sur les Gen- iratitis de la Med. Pratique, t. vii. p. 36. et seq.—Laydet, Archives Gener. de Med. t. xx. p. 430.—Rayer, in Diet, de Mid. t. xi. p. 460.—J. Frank, Praxeos Medica;, kc. vol. ii. £ars ii. sect. i. p. f>75. (See also the Bibliography of •ROPSYJ and of DllOPSY OF THE PERICARDIUM.) VIII. Dropsy.Congenital (Hydrops Congeni- tus; Dropsy ofthe Fatus andnew-born Infant). 174. Defin.—Effusion of watery fluid in the serous cavities, or cellular tissue, generally con- 55 sequent upon disease of the mother, or upon or ganic change in the appendages, or in some o) the viscera, or the fatus, or upon both causes. 175. Congenital effusions of fluid are found — (a) in the ventricles, or between the membranes of the encephalon; (b) between the membranes of or in the spinal cord; (c) within both the head and the spinal canal, in the same case; (d) in the abdominal cavity; (e) in the subcutaneous and other parts ofthe cellular tissue; (/) in the cavi- ties ofthe chest — the pericardiac and pleural; and, generally, in the above sequence, as respects frequency of occurrence. They are observed in the foetus at the full term of utero-gestation, and in abortions chiefly during the middle and latter months; and are, with the associated diseases either of the uterus or of the appendages of the fcetus, the cause of its death, or of its premature expulsion. 176. i. Congenital Hydrocephalus, (Hydroceph. congenitus) sometimes appears, as other forms of congenital dropsy, dependent upon disease of the uterus, or on constitutional taint in the parent or parents, or upon organic change in the placenta or umbilical cord. In rare in- stances it has been associated with ascites in the mother, or with dropsy of the amnion; but it more frequently occurs without any such connection. In these latter cases it may be imputed to a mor- bid action seated in, and more strictly limited to, the membranes, or internal cavities of the brain. It is often attended by an arrest of the formation of the encephalon at some stage of the process; but, in other cases, the brain is fully, if not more than usually, developed. When the fluid effused, either in the general cavity of the arachnoid, or in the ventricles, is considerable in amount, the os- sification of the cranial bones is interrupted gene- rally towards their sutures, but occasionally in other parts; and, in these situations, the mem- branes are often protruded to a greater or less extent, forming, with the scalp, a watery tumour (hydrencephalocele), which may be large at birth, or scarcely perceptible, and may subsequently disappear altogether, or become larger. When the effusion is chiefly in the ventricles, the dis- tended cerebral substance, and the membranes, with more or less of the fluid, constitute the tumour; unless the effusion has taken place pre- viously to, and thereby prevented, the develope- ment of the cerebral substance and hemispheres. Hence the character of the rupture depends upon the situation of the fluid ; and its form, upon the size of the aperture through which it presses Some forms of the disease approach to hemi cephaly; a large portion of the cranium being wanting, aud the protruding brain being covered by a thin membrane. In other cases, the opening is small, narrow, or cleft-like, and the protrusion is either small or has a narrow neck; the fluid being, in such cases, usually effused between the membranes. These ruptures are most frequent in the back of the head, in different parts of the occipital bone, and in the lambdoidal suture; and less frequently in the top, sides, and front of the cranium. (See the Cases and Writers referred to.) 177. Congenital hydrocephalus arises at va- rious epochs of foetal existence. At the earliest periods, it interferes more or less with, or entirely arrests, the formation of the brain, and cranial 650 DROPSY, CONGENITAL — of the Spine. bones. At a later epoch, or that most nearly approaching parturition, the brain and its enve- lopes may be not merely fully formed, co-exist- ently with effusion, in the ventricles, but even more than usually developed for the period of existence. A very large proportion of cases of chronic hydrocephalus commences before birth; the effusion slowly increasing after this period, and expanding the sutures. Meckel, indeed, supposes that all cases of the chronic internal dropsy of the head begins at this epoch; but certainly, in some, although the smaller number, the disease originates after birth. Not infre- quently water collects to an extent that precludes delivery until the head of the foetus is opened, and the water evacuated. Occasionally the col- lection is so small at birth, as to render its exist- ence somewhat doubtful, the signs of its presence gradually disappearing with the growth of the in- fant. In a few cases, in which effusion is more evident, an equally favourable result takes place. Congenital hydrocephalus is often associated with congenital dropsy of the spine, and various mal- formations. (See Dropsy of the Head — Chronic.) ii. Congenital Dropsy of the Spinal Cord. — Syn. Hydrorachis, Hydrorhachitis (from vdtuo, water, and "pa/i?, the spine), Water in the Spine, Spina bifida, Cleft Spine; Hydrorr- hachia dehiscens, J. P. Frank; Hydrops Spina; Wassersuch des Riickgrates, Germ.; Idro- rhachitide, Ital. 178. Defin.—A collection of a watery fluid between the membranes of the spine, generally occasioning a tumour through an aperture in the canal, occurring during fatal existence, or be- coming apparent soon after birth, and observed either in the prematurely born, or in the full- timed fatus, whether dead or living. 179. Congenital dropsy of the spine is often complicated with internal dropsy of the head, hemicephaly, and with hydrencephalocele; and generally terminates fatally with paralysis. Cases, however, have occurred, of children living seve- ral years, and reaching puberty, with the disease. Palletta and Acrel met with one at seven- teen years of age; Henderson saw it at eight- een; Warner and Hochstetter, at twenty; Ca m p e r , at twenty-eight; and Co w p e r ,one who lived to thirty. I saw the disease, in 1822, in a female of nineteen, who menstruated regularly through ulcers in the thighs. The tumour was about thirty inches in circumference. The excre- tions were passed involuntarily; but, in other re- spects, she was then in good health. She died, however, in a few months afterwards. Although generally congenital, hydrorachis, with an aper- ture in the canal, has occurred after birth (Frank and Reydf.llet). In the most complete, but the most rare, form of the disease, the spinal mar- row is entirely wanting; the membranes having fallen together, usually slit at one or more places, or more or less degenerated, and adherent to each other, forming sometimes a closed sac filled with lymph (Otto). This condition may even occur without cleft of the vertebral canal. In the less complete states of this disease, the spinal marrow presents its rudimental forms, like pultaceous masses of medullary substance and blood; or loose and separate nervous bundles; or the ante- rior columns running parallel but separate from each other; or, as in the early stages of formation, open, broad, and flat behind. 180. In the more common state of the disease, there is found only in one, or very rarely in two, distinct places in the spinal column, a more or less large swelling containing water : in some cases flat; in others, semilunar; and in several, necked; their parietes consisting of the expand- ed spinal membranes, often adherent and other- wise morbid, protruded through the cleft in one or more vertebrae; and connected with the thin and distended common integuments. This watery tumour most commonly appears in the lumbar region, more rarely in the dorsal and sacral, and still more rarely in the cervical, excepting in cases of coexisting hemicephaly or hydrencepha- locele, in which the spina bifida always occurs in the neck, and, from this point, protrudes more or less outwards. The dropsy of the cervical spinal marrow is merely, in this case, a process from that of the brain; the degenerated brain being directly connected with the diseased origin of the spinal marrow, which is sometimes per- fectly natural below. The size ofthe cleft in the spine varies greatly : generally more than one of the vertebrae are open; and rarely there is found only a small round hole in one bone, by which the tumour is connected with the spinal canal. It is extremely rare to find the bones healthy, and the aperture merely through the interverte- bral substance. 181. The seat of the water is originally or naturally in the spinal marrow itself; which, at the part affected, is very much expanded, broken up, and even entirely destroyed; and often ex- hibits the canal in the axis of the marrow open and expanded up to the brain. The water is also sometimes contained, at the same time, be- tween the membranes of the cord; and, in rare cases, in them alone; whilst the cord itself is either healthy, or merely compressed (Acrel, Palletta, Vacca-Berlinghieri, Uro,u- hart). In those cases where the .fluid is con- tained between the membranes only, there is generally coexistent effusion between the mem- branes of the brain. When the fluid is in the marrow itself, there is likewise often effusion in the ventricles. Sometimes the swelling also con- tains hydatids. Dropsy of the spinal marrow oc- curs, in some rare instances, without any external swelling, and without cleft in the spinal column; so that the canal running in the axis of the spinal cord, and which is generally closed, becomes more or less widely expanded by the water, with coex- isting increased thickness of the cord itself (San- torini, Portal, Otto); or the water is effus- ed only in the substance of the cord, and one part ofthe organ is distinctly swollen (P. Frank). About one half of the hemicephalic monsters have also spinae bifidae. 182. Whatever may be the seat ofthe external tumour, it presents three varieties as to its aspect (Billard):—1st, That with the integuments covering the tumour in a healthy and uninflamed state; 2d, That with the skin discoloured, thinned, and sometimes permitting the exudation of a serous or sero-sanguineous fluid, indicating the approaching rupture of the parietes; 3d, That which is opened, and allows the effused fluid to escape through a fine ulcerated perforation, the vicinity of which is surrounded by a red, rugous, DROPSY, CONGENITAL —Causes and Treatment of. 651 and unequal elevation. The patient may live several months or years with the first variety of the disease; but death usually soon follows upon the second and third. The fluid effused varies in appearance with the state of vascular injection presented by the membranes. When these are injected, or apparently inflamed, the fluid is ge- nerally more or less turbid, or even flocculent; but this change may arise from the inflammatory action preceding the rupture of the external part of the parietes of the tumour. In other cases, the fluid is commonly limpid and pale. 183. The general symptoms of congenital hydrorachis, or cleft spine, are very diversified. They consist chiefly of debility, emaciation; pa- ralysis, generally, of the lower extremities; reso- lution of the sphincters; anaesthesia; inability to take the breast; convulsions; and stertorous breathing. The tumour has usually a globular or pyriform shape; sometimes a broad base, and, at others, a narrow neck; and varies from the size of a hazel nut to that of the adult head, or even larger when the patient lives many years with the disease. Congenital dropsy of the spbe, with external tumour, is sometimes associated with other congenital diseases or malformations; as dropsy either of the head or of some other cavity; vices of formation in the digestive canal (Voisin, Journ. de Med. X. xxi. p. 57.; Revolat, in Ibid. t. xxvii. p. 378.); umbilical hernia (Preuss, in Ephem, Nat. Cur, vol. viii. p. 128.; Sandifort, Observ. Anat. Pr. t. iii. p. 1—41.; Meckel, L cit. p. 679.); malformations of the urinary or genital organs, or the absence of one or more of these (Delfini, Opusc. Scelti di Milano, t. vi. p. 21.; Lobenwein, De Monst. Genit. Difformitate, in Mem. de V Acad. Imp. des Sden. de St. Petersb. t. vi. 1817.); imperforate anus (Lamarc, in Roux's Journ. de Med. t. xxxiii. p. 516.); and defect of various parts. 184. iii. Congenital An asarca,and Drop- sies of the Cavities of the Chest and Abdomen, are occasionally observed, particu- larly in the prematurely born foetus, either dead or living; and under the circumstances already stated (§ 176.). The occurrence, unless wheu the effu- sion is very great, or associated with extensive visceral disease, should, however, not be viewed as necessarily fatal. Cases have been observed, wherein the collection of water in the abdominal cavity of the new-born infant has been very con- siderable, and yet recovery has taken place. In some instances, the effusion, in this situation, has been so great as to impede parturition; and, in very rare cases, it has been found necessary to {mncture the abdomen of the foetus before de- ivery could be effected. Congenital encysted dropsy is very seldom met with. The case re- cently recorded by M. Petit-Mengin is one of the most remarkable on record. 185. iv. Causes of Congenital Dropsies. —(a) The remote causes of congenital dropsies are not frequently very obvious. They have been stated to consist of constitutional vice in the parents, particularly the mother; the syphilitic taint; the scrofulous and rickety diatheses; vio- lent mental emotions, as fits of anger, fright, &c; whatever inordinately excites the circulation in the uterine organs during pregnancy, as excessive venereal indulgences (Klinkosch, J. Frank); external injuries affecting the uterus or its con- tents; violent concussions of the trunk; and sup- pressions of urine in the mother (Frank, Bil- lard, &c).— (6) The more immediate causes are organic changes, and hydatids, in the pla- centa; alterations in the umbilical cord; tumours or other lesions of the uterus; inflammations or congestions in the viscera of the foetus, or inflammatory irritation in the serous membranes; tubercles in the liver and lungs; and tubercular thickening of the serous surfaces. The three cases recorded by Dr. R. Lee occurred in con- nection with dropsy of the amnion, and with dis- ease of the placenta, and of some one of the viscera of the foetus. In two, the effusion was seated in the peritoneal cavity, and in one of them it was associated with anasarca. It has been remarked by Michaelis and some other writers, that congenital dropsies, especially spina bifida, often occur in the same families with rickets. 186. v. Treatment.— Congenital dropsies may be somewhat benefited by medical treatment. When the aqueous collection is not great, and when the infant is well-formed, fully developed, and evinces little or no disease of any vital organ, we should not despair of success.— (a) Of the treatment of congenital hydrocephalus, particular mention will be made in that part of this article in which chronic hydrocephalus is discussed; and the same measures which will be recommend- ed in dropsy of the spine with external tumour, are in great measure applicable to the congenital collection within the head, but more particularly to that form which is attended by imperfect formation of the cranial bones and protrusion of the membranes and other parts external to the seat of the collection (Hydrencephalocele, see § 176.). In most instances of congenital hydrocephalus, bandaging the head, and con- tinued but gentle pressure, aided by the rest of the means advised in the next paragraph, seem most appropriate. 187. (6) Of dropsy of the spine, fyc.— The removal of this form of disease by ligature was practised unsuccessfully by Heister; and was more recently recommended by B. Bell. But what has been stated above relative to the patho- logical relations of the tumour, independently of the circumstance of its form being such as not frequently to admit of this treatment, will show that this method can be but seldom appropriate, and that it must be generally hazardous. Gentle pressure has been advised by Mr. Ab erne thy, and successfully employed in a case by Sir A. Cooper, who also resorted to puncture in another case, with a similar result. These methods have, however, been often practised in the dropsical tu- mours, both of the spine and of the head, but very rarely with advantage. In a case, however, ofthe latter kind, Mr. E. Thompson succeeded by ap- plying a ligature. Richter recommends setons to be inserted at a short distance from the tumour; Camper and Ac r e l , the application of discutient lotions; De Haen, the employment of defensive plasters; and Billard, gentle and continued pres- sure. Camper, Borsif.ri, the Franks, Rac- chetti, and Ollivier, are strongly opposed to repeated punctures; and state, that they excite inflammatory action in the membranes, and hasten an unfavourable termination. I believe that the tumour should be as little interfered with as 652 DROPSY, ENCYSTED —Causes and Pathology of. possible; that, if any local medication be resorted to, a simple discutient lotion — as one of vinegar, rose water, and spirit, or liq. ammon. acetatis — or a defensive and discutient plaster, with gentle pressure, will be found the safest and most suc- cessful ;— that, in addition to this, the abdominal secretions and excretions should be promoted, by means the least calculated to lower the vital powers;—that a healthy wet-nurse should be provided, to whom a gentle course of iodine may be administered;—that change of air, or resi- dence in a warm and dry air and locality, be directed;—and that the infant should wear soft flannel next the skin, and be warmly clothed. These have been the means I have employed in most of the cases of the disease I have treated; and they have often prolonged life, and dimi- nished the tumour, although, in many instances, I was unable to learn the ultimate result. When the exterior of the tumour becomes in- flamed, or the integuments thinned and disposed to ulceration, puncture may be then resorted to, as in the case recorded by Mr. Abernethy; but care should be taken to close the opening accu- rately after each operation, and to protect the part from the air and external injury by suitable applications. (See Dropsy of the Head— Treatment of Chronic.) 188. (c) As to the treatment of the other forms of congenital dropsy, but little need be added to the above. In some instances, it may be requisite to commence with the application of one or two leeches. Purgatives are generally requisite, and should be often repeated, and alternated with, or followed by, diaphoretics and diuretics, and assist- ed by the use of slightly alkaline baths, of a tem- perature ranging from 85° to 94°. Many of the cases of these forms of congenital dropsy are be- yond the reach of medical aid; but, when the infant is in other respects well formed and strong, the existence of active congestion in, or of vascular determination to, some one of the viscera of the cavity in which the collection is formed, or of in- flammatory irritation in the serous membrane, may be suspected, and moderate local depletions, and active alvine evacuations, aided by means calcu- lated to relax the cutaneous surface, should be employed. Biblioo. and Refer. — i. Conoenit. Dropsy of the Head.—Ruysch, Thesaur. Anat. ii. obs. 52.—Blancard, Anat. Pract. Rar. cent. i. obs. 80., cent. ii. obs. 15.—Haller, Disput. Anatom. t. vi. p. 320.—Socin, Dissert, de Fcetu Hy- dropico. Bas. 1751.—GeUer, De Pa tu difficili ex Hydrope Foetus. Lips. 1762.—Marcorel, Mem. pr£s. &. l'Acad. t. iv. p. 458.—Odier, Recueil Period, t. vi. p. 289.—Mende, in Nova Acta Acad. Nat. Cur. vol. xi. pars ii. p. 443.—Penada, Saggio d'Osservazioni e Memorie, 4to. Padua, 1793.—Osi- ander, Handbuch der Entbindungsk. kc. part ii. p. 291. (In an embryo of two or three months.)—H. Earle, in Med- ico Chirurg. Trans, vol. vii. p. 427,—Rudolphi, Tab. i. fig. i. (In a fatus of two months.)—Meckel, Handbuch der Path. Anat. b. i. p. 260. (Considers that all cases of chronic hy- droceph. are congenital.)—A. J. Wenzel, De Hydrocephalo Congenito, 8vo. Ber. 1823.—J. Frank, Praxeos Medicae Universas Pra-cepta, Sic. pars ii. vol. i. sect. i. p. 251.—E. Thomson, Lond. Med. Renos. Nov. 1824.—Meckel, De- scriptio Monstrorum nonnul. kc. 4to. Lips. 1826, p. 83. (In a fatus of six weeks.)—Billard, Des Mai. des Enfans Nouveaux-nes, kc. P;>ris, 1828, p. 451.—.4. W. Otto, Comp. of Path. Anat. bv South, p. 375.—Caucal, Lancette Fran- caise, No. 76. 1833. ii. Conoen. Dropsy of the Spine.—Ruysch, Observ. Anat. Chir. obs. 34, 35, 36.—Bonet, Sepulchret. 1. i. sect. xvi. obs. 4. (With hydroceph.)—Hochstetter, De Spina Bifida. Alt. 1703.—Salzmann, De Quibusdam Tumoribus tunicatis extern. Arc. 1709.—Morgagni, De C. et S. M. epist. xii. xlviii.— Halle; Element. Physiol, vol. iv. p. 87.— Portal, Mem. de l'Acad. des Sciences, an. 1770, 1771. (With hydro- ceph.)—Warner, Observ. in Surgery. Lond. 1784, p. 136— Srott, Rat. Med. par* vii. p. 47. (With hydroceph.)—Oehme, De Morb. Recens Nat. Lips. 1773.—S mdifort, in Observ. Anat. Pathol. 1. iii. cap. i.—Oberteuffer, in Stark's N. Ar- chiv f. d. Gebuctsh. vol. ii. par. iv. p. 624.—Olces, An Ac- count of Spina Bifida, &c. Cambr. 1810.—Fielix, m Richter's Chirurg. Biblioth. b. ix. p. 185. (The whole spine bifid, the spinous processes being wanting.)—Michaelis, in Ibid. b. vi. p. 133.—J. P. Frank, De Curand. Horn. Morb. 1. vi. pan i. p. 198.—Moeckel, De Hydrorrhachitide Commentatio. Lips. 1822.—Abernethy, Surg, and Physiol. Essays, part i. p. 75. —Meckel, Handbuch d. Patholog. Anatom. b. i. p. 35. 37— Palletta, Exercit. Path. cap. 10. art. 3. Nov. Ifr20—A. Cooper, Tians. of Med.-Chirurg. Society, vol. ii. p. 324.— Neuendorf, De Spinae Bifida; Curatione radicali. Berol.1820 —Vacca-Berlinghieri, Storia di una Idrorachia. Pav. 1820. —Jukes, in Med and Phv>. Journ. Feb. 1822.—Jos. Frank, Praxeos Med. Univers. Pra-cept. vol. i. pars ii. sect. ii. cap. 4.—Rozetti, in Journ. des Progre's des Scien. Mtd. t. v.— Baron, London Med. Repository, ed. by Copland, Aug. 1824. —Ollivier, Traite de la Moelle Epiniire et deses Mai. t. i. p. 207.—Duges, in Revue Medicale, kc. April, 1823.—Otto, Compend. Anatom. Pathol. 8vo. Bresl. 1829. (Results ofthe examination of thirty-three cases.)—Brewerton, in Edin. Med. and Surg. Journ. vol. xvii. p. 251.—Locock, in Ibid. vol. xviii. p. 378.—Lindsay, in Lond. Med. Repos. Jan. 1826.—Billard, Traite des Mai. des Enfans, &c. p. 582__ S. Malins, in Liverpool Med. Gaz. vol. i. p. 27. iii. Conoen. Dropsy of the Cavities of the Tho- rax, Abdomen, &c.—Blancard, Op. cit. cent. i. obs. 93.— Reidlin. Lin. Med. 1696. p. 38.; Ephemer. Nat. Cur. dec. i. ann. 1. obs. 42., cent. ii. ann. iii. obs. 153.—De Haen Opusc. quaedam inaedit. pars i. p. 4.—Roux, Journ. de Med. Chir. et Pharm. t. xvii. p. 18U.—Humberg, in Stark's Ar- chiv, &c. b. vi. p. 396.—Ollivier, in Archive* Gener. de Med. t. viii. p. 383.—Andry, in Journ. des Prog, des Sciea. Med. 2d ser. t. i. p. 126.—R. Lee, in Med. Gazette, vol. vii. p. 385.—Petit-Mengin, in Gazette Medicale de Paris, No. 50. 1833. (One case of abdominal dropsy, and another of encysted.) IX. Dropsy, Encysted.—Syn. Hydrops Sac- catus; Hydrops Cyslieus, Auct. var.; Die Sack- wassersucht, Germ.; Hydropisie enkystie, Fr. 189. Defin.—The fluid enclosed in a cyst, generally of a serous structure internally, and of adventitious formation; giving rise to local symptoms resembling those caused by effusion into natural cavities. 190. The origin of serous cysts is discussed iu the article Disease (§114.); it therefore re- mains only to notice those excessive collections of fluid in them, which are distinguished with difficul- ty from accumulations in natural cavities. The encysted productions, which either contain more or less consistent secretions, or are of so small size as not materially to affect the bulk of the organ in which they are seated, or the functions of parts adjoining, are considered in connection with the other lesions of their respective seats In the view about to be taken of encysted collec- tions of fluids, mention will be made only of those which possess, in many respects, a drop- sical character, and which have generally been considered as such by writers and practitioners, although even they may possess no true claims to I this distinction. 191. A. Causes. — The causes of common dropsy have generally no influence in producing the encysted. The same state of action, to which the formation of the cyst in the first instance is to be attributed, evidently is the main agent in the secretion of its accumulated contents. Of what this state consists, and of the causes in which it originates, but little is really known. When re- marking on this and similar changes (see Dis- ease, § 111.), I stated that the origin of serous cysts cannot be considered as truly inflamma- tory; but that it may be imputed to a modified nutrition, frequently connected with a weak- DROPSY, ENCYSTED —Prognosis and Treatment of. 653 ened or depraved state of the constitution; mo- difications of the formative processes—of the organic actions of secretion and nutrition — being more apt to occur from causes which deflect them from their healthy course, in such constitutions, than in the sound and vigorous. This view is important, inasmuch as it is based on an attentive observation of a number of cases of this descrip- tion, aud as it leads to a more successful practice than is too frequently adopted. 192. B. Prognosis.— Encysted collections of fluid, as long as they do not reach the extent of im- peding the functions of adjoining organs, seldom occasion any serious disturbance. In this respect they are different from effusions into natural cavi- ties ; and, when they give rise to dangerous or fatal result*, it is owing more to this injurious action on surrounding parts, than to any change they induce in the circulating, secreting, and natural func- tions. When not injuriously interfered with, and when the system is not improperly lowered, or if it be enabled to resist their increase, all the func- tions frequently proceed without any material disturbance, and these collections often remain long stationary. But, when the constitutional powers receive a severe shock from any cause ; when the patient is imperfectly fed, or is made the subject of a meddling or active surgery; the cysts become the centre of a morbid determination of the organic actions; chronic inflammation supervenes in them; the accumulation of fluid advances rapidly, and the vital resistance is subdued. In some cases, the secretion proceeds in the interior of the cyst with greater rapidity than the cyst itself can either yield or be deve- loped, and hence it is ruptured, and its contents effused. This circumstance may hasten an un- favourable issue; or, when the cyst is small, favour its disappearance or transformation. 193. Encysted dropsies are, with some excep- tions, incurable when they have reached a large size, and when, either from this circumstance, or from their situation, they admit not of being re- moved entirely. But, in many instances, especi- ally when they are seated in the ovaria, a judicious constitutional treatment will often pre- vent their increase for years,— sometimes during the greater part of a very long life,— or will even cause their entire disappearance, or transform- ation into an inert substance. 194. C Treatment.— As to the indications of cure, only a few general observations are here necessary. In all encysted formations, particu- larly in those now under consideration, it may be viewed as a law, from which there are ex- tremely few exceptions, that, in proportion as vital power, and its manifestations in the secreting, assimilating, and excreting organs are promoted, without materially exciting the vascular action, or heating the body, will the progress of these productions be overcome, or their diminution effected; whilst their increase will be both great and rapid in an equal ratio with depression of constitutional energy, or with disorder of any of the functions now alluded to. A healthy and vigorous performance of the various organic ac- tions resists the progress of all adventitious form- ations; and an opposite state favours their increase. This rule holds in respect of all productions of a parasitic kind, and in all the kingdoms of or- ganised nature, and is observed in both the 55* physical and moral manifestations. The parasitic formation or animal can grow only at the ex- pense of the weak ; the robust frame resists it, and denies it nourishment; whilst the weak fur- nishes it with means which are slowly but surely turned to its own destruction. 195. During the treatment of encysted dropsies, care should be taken not to resort to any measures that may irritate or inflame them, particularly when they have acquired a large size. On this account, puncturing or paracentesis should be resisted to the utmost — until extinction of life would follow on its being longer deferred ; and, when thus made a dernier ressort, the operation should be performed by a scalpel and lancet, with which latter the sac should be opened; the utmost care being taken not to admit the air. I have seen, on numerous occasions, the ill effects of not attending to this injunction, and of leaving a canula, or tent, in the wound, the inflammation thereby induced in the cyst, giving rise to so exteusive a secretion, and so much constitutional disturbance, that the patient has rapidly sunk. 196. The preparations of iodine, when judi- ciously exhibited, are the most generally applica- ble and efficacious means that can be employed in this class of diseases. But they ought to be exhibited in very small doses, much diluted or reduced, and long persisted in. They become injurious as soon as they give rise to the slightest indication of irritation of the digestive organs. I have employed them extensively and constantly since 1819, when I brought some of them with me from the Continent. At that time they could not be procured in London. They are most be- neficial when prescribed internally; but they are also of use externally, if they be directed so as not to inflame the part to which they are applied (see F. 332. 766 — 769.). When the debility is considerable, the ioduret of iron, taken in any aromatic infusions, the secretions and excretions being at the same time promoted by an aperient pill at bed-time, will be of essential ser- vice. I have lately prescribed it in several cases of cachectic disease, with remarkable benefit. The diet, in all encysted dropsies, should be light and nutritious; and the patient's mind be agreeably engaged: change of air, or residence in a pure, temperate, rather warm, and dry air, ought also to be recommended. 197. The situations in which encysted dropsy is most frequent, are numerous; and if all the places in which large serous cysts have 1 been developed were taken into the account, it may be said that they comprise every part and or- gan ofthe body. Encysted dropsy, however, has | been observed under the integuments, by Sc h e n k , Van Swieten,Cruveilhier, and others, form- ing very large lymphatic tumours; within the head, as shown in the article Brain ; between thepleura and the intercostal muscles (Haller, Desault, &c.); in the mediastinum; in the substance ofthe lungs (Stof'rk, Maloet); in the cavity ofthe thorax, and in that of the pericardium (Mercker, Dupuytren, Itard, &c); between the perito- neum and abdominal parietes (Achol/.ius, Mor- ! gagni, MoRAND,and J. P. Frank); in the oua- I rium, forming ovarian dropsy; in the Fallopian tubes (Riedlin, Douglas, Blankard, Bail- I lie, Seymour, &c); in or connected with the 'uterus,— Hydrometra, fyc. (Gruner, Odier, 59 654 DROPSY, ENCYSTED, OF THE OVARIUM —Pathology of. Lafosse, Rayer,Thomson, &c); connected with the liver (Alix, Corvisart, Leroux, Frank, Lassus); in the kidney (Morgagni, Houston, Walter, Corvisart, J. Johnson, Howison); in the omentum (Hasenoerhl, De Ha en, Portal); in the mesentery (Horstius, Tulpius, Sauvages, Morand); and in the spleen (Morgagni, Baader, &c). Ofthe most important only of these, I now proceed to take a more particular notice. In some cases of very large encysted dropsy seated within the abdomen, the exact origin of the cyst can hardly be ascertained. Of this kind appears to be the instance recorded by Mr. Coulson (Med. Gazette, vol. ix. p. 577.), which was frequently tapped. Upon dissection, the cyst was found to adhere to the abdominal parietes, and to several of the viscera, and to consist of three layers. The ovaries were healthy. Similar cases are published by Portal and Cru- veilhier (Anat. Patholog. vol. i. p. 268.). i. Dropsy of the Ovarium.— Syn. Hydrops Ovarii, Ovarian Dropsy, Dropsy ofthe Ovary; Hydroophorie, Boivin and Duges; Die, Was- sersucht der EierstOcke, Germ.; Idropisia di Ovaria, Ital. 198. Defin.—Swelling, commendng with ten- derness, pain, or weight in the iliac region of one or both sides,and irregularity ofthe menstrual discharge; the swelling gradually extending over the abdomen, and attended by obscure fluctuation. 190. A. Pathology.—This is the most frequent species of encysted dropsy, and of the greatest importance in a practical point of view. It is very often complicated with other organic changes in the ovaria (see article Ovaria — Diseases of), peritoneum, uterus, and tubes; but it also frequently consists only or chiefly of a collection of a greater or less quantity of fluid in one or more cysts, into which the substance of the ova- rium seems to have been converted; owing to the enlargement of one or several of them giving rise to atrophy of the proper structure of the organ. These cysts have been mistaken for hydatids, from which, however, they may be dis- tinguished by their being nourished by vessels sup- plied from the parts in which they are formed ; whilst hydatids are not thus supplied, but are nourished by their own vessels, and have an in- dependent life. Sometimes " one or both ovaria are converted into simple cysts; the whole ofthe cellular substance and vesicles disappearing, that which was the fibrous coat of the ovarium becom- ing the fibrous coat ofthe cyst." (Dr. Seymour.) 200. The Graafian vesicles, which, in the healthy state, are of the size of millet seeds, fre- quently become as large as almonds, are filled with a limpid fluid, and their internal membrane is very vascular. This appears to be the com- mencement of the simplest form of ovarian dropsy; or, at least, a change, which may proceed no fur- ther, but which sometimes does proceed to an extent which constitutes this disease. When these vesicles enlarge to a greater degree than the size of a filbert or almond, it is always on the side nearest the proper coat of the ovarium ; the rest of the ovarium, as shown by M. Cruveilhier and Dr. Sevmour, appearing, when the cyst reaches a large size, as if atrophied at the parietes of the cyst. In this manner is sometimes formed an enormously large single cyst, having the proper fibrous coat of the ovarium and peritoneum for an external covering; the internal membrane, or the parietes ofthe vesicle, secreting a prodigious quan- tity of fluid. In many of these cases, especially in those of long duration, the parietes ofthe cyst un- dergo various changes, and are thickened, hard- ened, cartilaginous in parts, or even ossified. Their external surface, in their earlier stages, are some- times smooth, not infrequently inflamed or very vascular: and form adhesions with adjoining parts ofthe peritoneum and contiguous viscera, or with the fimbriated extremities of the broad ligament, or with the fundus of the uterus (Boivin, Sey- mour, Duges). In their more advanced states, also, their surface becomes the seat of chronic in- flammation, of tuberculation, or both; and in this change the rest of the serous surface of the abdo- men, or parts of it only, may participate. In some instances, the marks of associated inflammatory action in the peritoneum are indistinct; but this membrane not infrequently contains, in these cases, more or less fluid, the encysted dropsy thus being complicated with ascites. The interior of the sac, or cysts, is commonly smooth, and re- sembling a serous surface (Morand, Burns); or it is lined with a false membrane: it is, in some cases, irregular or mamelonated; and, in others, imperfectly divided by incomplete parti- tions (Cruveilhier) 201. The fluid contained in these cysts varies remarkably. In some cases, particularly when it is lodged in one, or a few cysts of a very large size, it is serous, or mixed with a ropy or mucous mat- ter. In others, it is dark-coloured and resembles coffee. Where the cysts are more numerous, their contents are generally thick, gelatinous, and of a brown colour of varying depths of shade. The fluid is also, but more rarely, of the appearance and consistence of custard; and occasionally it re- sembles honey. I have seen it, in some instances, where the accumulation was remarkably great, brown, thick, and gelatinous; and in others, its characters have changed at subsequent stages, especially after tapping; and it has become gray- ish, dissolved, ichorous, flaky, or puriform and even offensive. The quantity which collects, particularly when there is only one cyst, and when its contents are serous or watery, is sometimes very great. Wepfer, Haller, Monro,and Frank have found as much as 120 pounds of fluid in a single cyst, and Muller as many as 140 pounds. When the necessity of resorting to puncture has once become imperative, the rapidity with which the fluid is again formed is often remarkable. Morand drew off427 pints in ten months; and Martinkau nearly 500 in a twelvemonth; and, from the same patient, upwards of 6600 pints, by eighty operations, within twenty-five years. Sir A. Cooper thinks, with great probability, that the case of Mrs. Mumford, who was tapped 155 times in less than four years, was one of ovarian dropsy. When the ovarium contains a number of cysts, is lobular, and irregular in its surface and firmness, each of the individual cysts often is filled by a different and peculiarly characteris- ed secretion — which is either watery gelatin- ous, sanguineous, fatty, &c. ; and, when the tu- mour has been punctured, partially decompos- ed or putrid, and mixed with gaseous fluids (De Haen, Boivin, Duges, and myself). In rare instances, sebaceous matters with long hair have been found in the same ovarium that con- DROPSY, ENCYSTED, OF THE OVARIUM—Causes, Symptoms, etc. 655 tained large dropsical cysts, and even in the same cyst with the watery collection: the cyst in which the hair and fatty substance had been formed having subsequently become the seat of dropsical effusion. 202. B. Causes.— (a) The predisposing causes are, the scrofulous diathesis; debility, how- ever induced; frequent or excessive menstruation, and venereal indulgences. The disease occasion- ally commences as early as the first appearance of puberty. J. P. Frank saw it at thirteen, and M. Itard at fourteen years of age. Marjolin states, that it may begin before puberty; but I know of no such occurrence. It is most com- mon between the ages of twenty and fifty. It may commence soon after the cessation of the catamenia; but, although chronic cases of it are found in very old females, yet it rarely originates at an age much beyond fifty. It often follows abortions. 203. (b) The exciting causes have not been satisfactorily shown : but it has been very gene- rally imputed to external injuries, succussions of the pelvis, the mismanagement of parturition and abortions; or to cold, fright, and anxiety of mind. From much attention to this disease, I have in- ferred that it is occasionally consequent upon in- flammatory action in the ovaria or uterus, or connected with this change in its earlier stages. Hence its causes may be considered to be, in some cases, those in which inflammatory action in these organs generally originates. Yet there are numerous objections to this view; for even when the tenderness and pain in the region of the ovaria, accompanying its commencement, are greatest, there is also a frequently recurring and copious menstruation, indicating an excited, rather than an inflamed, state of these organs. From various considerations, and a review of the cir- cumstances in which the disease seemed to origi- nate, it is not improbable that it is connected with an often excited, but an imperfectly gratified, sex- ual appetite. Hence its frequency in females who are sterile, or whose state of health is insufficient to the developement of a healthy and vigorous orgasm, owing either to premature and illicit in- dulgences, or to previous disease. 204. C. Symptoms and Progress.—Ova- rian dropsy is very commonly far advanced before recourse is had to medicine. It usually commen- ces with irregularity of the menstrual discharge, and disorder of the excretion of urine, which is either voided frequently, or is long retained. There is also severe pain in the loins, with pain, tenderness, and swelling in one or both iliac re- gions. In some instances, the pain shoots through the abdomen, and down the thighs; and occasion- ally there is numbness, haemorrhoids, or complete strangury, owing to the pressure of the enlarged ovarium before it rises out of the pelvis. The catamenia, at this period, is frequently either co- pious or of too frequent occurrence; but it is rarely altogether suppressed. Various hysterical symptoms also come on; and disappear at a later stage. The bowels are usually costive; but they are sometimes irregular, or relaxed. As the ma- lady proceeds, the patient experiences various dyspeptic symptoms, and often nausea and vomit- ings, as in the early months of pregnancy. The mammae also enlarge, and the areola? around the nipples assume a darker shade. Dr. Seymour states, that, when both ovaria are affected, the catamenia are always absent; but, when one only is diseased, this evacuation is either absent or ir- regular. This does not agree with my experience, the results of which I have just now given, as regards the early stages of the disease; but, as respects the last stages, particularly in the more chronic cases, the observations of this physician seern to be correct. With the increase of the tumour, various inflammatory phenomena, refer- rible chiefly to the peritoneum, and commencing in the pelvis, but often extending upwards to parts of the abdomen, supervene. 205. The progress of the tumour and abdomi- nal enlargement is extremely various. Occasion- ally the ovarium, whether it consist of a number of cysts, or of one or few, increases very slowly. It sometimes remains long stationary; afterwards augments rapidly, and fills, ultimately, the whole abdomen; and in rarer instances it recedes, or even entirely disappears. It proceeds more reg- ularly, however, in most cases, until it gives rise to appearances rendering the diagnosis very diffi- cult. The general health, as already stated in respect of encysted dropsies, continues but little impaired, until the morbid accumulation has ad- vanced so far as to disturb the functions of ad- joining viscera; but this is not uniformly the case; for the means used to cure it not infrequently are sources of disorder, deranging the natural func- tions, and thereby favouring the increase of the disease. When the collection rises as high as the epigastric region, and the abdominal distension is great, the functions of the stomach are often completely overturned, and the constitutional powers rapidly sink; singular and unexpected changes, however, sometimes occur, even in the most chronic cases. Dr. Baillie mentions an instance of its spontaneous disappearance, after it had existed thirty years; the patient remaining, subsequently, in good health. The accumulated fluid is also occasionally discharged into some part of the large intestines, having previously formed adhesions with it; or into the vagi- na, pressure on the tumour increasing the dis- charge. Instances of this have occurred to Dr. Elliotson, Dr. Montgomery, myself, and others. In a case treated by me some years ago, and put upon a course of iodine, the catamenia were profuse every fortnight or three weeks. The tumour, which filled the whole abdomen, remained long stationary, and ultimately burst into the large intestines. It did not return again until upwards of a twelvemonth: ultimately the patient was so much benefited as to leave off treatment. Dr. Seymour adduces an instance, in which the morbid collection was discharged both by the intestines and by the vagina, and re- covery took place. Sometimes it forms adhe- sions to the abdominal parietes, and bursts exter- nally at the umbilicus. A permanent cure is often effected by judicious management under the fore- going circumstances. A case was seen by me, in which adhesion of the tumour took place, to the parts adjoining the puncture by which its contents had been drawn off. The cicatrix ulcerated, and the fluid was afterwards discharged by degrees through the opening, and the patient recovered. A nearly similar instance of recovery occurred in the practice of Mr Barnwell. When the fluid finds its way into the peritoneal cavity, the result 656 DROPSY, ENCYSTED, OF THE OVARIUM —Diagnosis —Treatment. is, in my opinion, generally fatal, although some authors contend that the fluid may be absorbed from this situation, and the patient recover. This, however, is certainly a very rare occurrence. The best authenticated case of restoration from effusion of the contents of the ovarian tumour into the abdomen is recorded by Dr. Blundell, in his published lectures. 206. D. The Diagnosis of ovarian dropsy is not always easy. It may be mistaken for preg- nancy, for ascites, for hydrometra, or for tumour or abscess of some adjoining part. The appear- ance of swelling and pain in one side, or both, of the pelvis, in connection with irregularity, with- out suppression, of the catamenia; this swelling being at first but little, or not at all, changed by position—by lying on either side or by the erect posture;—obscure fluctuation as it expands, with a sense of elasticity, and sometimes of irregular- ity in it;—the motions and activity of the patient not being very materially impaired, or not in proportion to the magnitude of the tumour;— the principal abdominal organs not having evin- ced much disorder, or signs of organic change, previously to the swelling, and their functions not being greatly disturbed during its course;—its slow increase, its situation, its direction to one side and limitation to the lower regions of the abdomen when the patient is supine, until a late stage of the disease;—the inefficacy of purgatives and of diuretics in producing any diminution of it, and the not materially lessened secretion of urine, until after the disease has advanced very far, or until the fluid has been drawn off by art; — the more healthy aspect of the patient than in ascites,—and pain, stupor, or oedema of the thigh, leg, and ancle, having been complained of, on the same side with that where the swelling com- menced,—will serve, when carefully considered, either separately or in conjunction, to guide the practitioner. These phenomena, however, may not be uniformly present, but many of them will—and will be so associated as to leave little doubt as to the nature of the disease, particularly when aided by an examination per vaginam, and also per rectum. At the commencement of the malady, the local symptoms have sometimes been so manifest, and attended by so much pain in the back, and pain and oedema of the lower extremity of the same side, as to have been mistaken for psoas abscess. The disordered ex- cretion of urine and strangury, and the evidence obtained by examination, will, however, gener- ally indicate satisfactorily the nature of the dis- ease. Dr. Macintosh states, that the tumour may sometimes be felt between the vagina and rectum, before it becomes much enlarged; the os uteri being, in such case, tilted forwards close to the symphysis pubis, so as to resemble retro- version ofthe uterus; but an examination by the rectum will make the nature of the affection evi- dent. When the increase of the ovarian tumour is slow, and it rises in the abdomen by a narrow neck before it is perceived, it may be mistaken for enlargement of some other organ; especially if it have formed adhesions with the parts in con- tact with it. The difficulty of diagnosis is also in- creased by the presence of fluid in the peritoneal cavity,—a circumstance which occasionally oc- curs. When this is suspected, or when the diag- nosis is difficult, the patient should be examined in the recumbent posture, when the ascitic fluid will be found to gravitate towards the hypochon- driac and lumbar regions; and the limits of the ovarian tumour may be ascertained. The history of the early stages of the case, and the recurrence of the catamenia during the greater part, or even the whole, of its course, its chronic duration, and the absence of the progressive changes of the os uteri characterisingpreg-nanei/, will sufficiently dis- tinguish it from that state; the uterus being move- able and light upon examination per vaginam, pressure on the hypogastrium at the time not affect- ing, or propagating any movement to, this organ. 207. E. The Prognosis will depend entirely upon the constitutional powers of the patient, and the progress the disease has made. Although it should be generally unfavourable, and always ex- pressed with caution, and with much reservation, even in cases apparently the most favourable, yet we may entertain reasonable hopes that the pro- gress of the disease may be checked by careful regimen and treatment, particularly when the energies of the constitution are unbroken, and the digestive and excreting functions are not ma- terially disturbed, nor the progress ofthe swelling rapid. J. P. Frank met with a case where it commenced at thirteen, and yet the patient reach- ed the great age of eighty-eight years. The oc- currence of tenderness in the abdomen, any man- ifest diminution of the patient's activity, its com- plication with ascites, emaciation, accelerated pulse, great disturbance of the functions of the stomach, and the necessity of having recourse to paracentesis, are all unfavourable circumstances. 208. F. Treatment. — The utmost care should be directed to the removal of all sources of irritation from the uterine and adjoining viscera. The urine ought to be drawn off, if its excretion be interrupted; and particular attention should be paid to the state of the bowels, the evacuation of which must be procured daily, by cooling aperi- ents, or laxatives conjoined with gentle tonics, when they require it, or by means of tepid and emollient injections. In the early stages of the disease especially, and when pain, tenderness, and other symptoms of inflammation are present, par- ticularly if the catamenia are deficient or delayed, local depletions by cupping on the loins or sacrum, or the application of leeches, or cupping about the tops of the thigh, are requisite. External irritation should afterwards be prescribed; and, as soon as the symptoms of inflammation are removed, the patient should be put upon a mild course of iodine. The mode of counter-irritation deserves attention. Blisters increase the stran- gury that is often present at this stage, and excite the vascular system. I have usually, therefore, had recourse to the tartarised antimonial oint- ment, or to the insertion of issues or setons in the insides of the thighs. When symptoms of irritation exist in the uterine and urinary organs, they must be removed, by the sub-carbonates of the alkalies, with nitre, taraxacum, and hyoscya- mus given in the infusion of calumba, or the infu- sion of cinchona. The course of iodine should be assiduously persisted in, and the preparations adopted should be given in small doses, much dilu- ted. The hydriodate of potash, or the ioduretof iron, are upon the whole the preferable combina- tions of this substance. Iodine, in some one of the preparations—liniment or ointment—may also be DROPSY, ENCYSTED, OF THE FALLOPL4.N TUBE. 657 used externally. In this case it should be rubbed upon the insides of the thighs; where, if it should produce irritation of the integuments, the effect will be the more salutary. 209. Cathartics and diuretics have no influ- ence upon the disease, further than to accelerate its progress, if they be used in such a manner as to weaken the powers of life. Purgatives of a tonic kind, however, maybe employed to evacuate faecal matters, and to promote the intestinal se- cretions; but such only, as are not calculated to excite or irritate the large bowels, should be se- lected; as the supertartrate of potash with con- fection of senna, or the infusion of calumba or of gentian with infusion of senna. As to diuretics, I have seen no benefit derived from them, with the exception of those which possess tonic and astrin- gent properties, as the balsams and terebinthinates; the latter of which have been productive of benefit, particularly when used in the form of liniment or epithem. Camphor and narcotics are also useful palliatives, especially opiates. The liquor potassee, and Brandish's alkaline solution, in suitable vehicles, and aided by sarsaparilla, by local de- pletions when tenderness in the situation of the tumour is perceived, and by setons, have also been of great service in some cases in which I have prescribed them. The good effects of vomit- ing in swelled or inflamed testicle have induced some practitioners to have recourse to emetics in the early stage of this malady. Dr. Percival records a case in which they proved of service; but I have had no experience of the practice. Mr. Abernethy prevented the reaccumulation of the fluid after tapping, by repeated blistering. Dr. Hamilton (On MercuiHal Medidnes, fyc. p. 202.) states that he has cured seven cases by percussion, or patting, for a long time daily, on the tumour, using a bandage so as to make con- stant compression, giving a solution ofthe muriate of lime, and employing the warm bath. Many instances will, however, be found to confirm the opinion of Dr. W. Hunter (Med. Observ. and Inquiries, vol. ii. p. 41.) "that the patient will have the best chance of living longest under it, who does the least to get rid of it." In addition to the above means, but little can be attempted with much hopes of success. The chief objects are to support the vital energies throughout the frame,— to promote a healthy assimilation, and the excre- tion of effete matters,— to ward off all irritation, physical and moral, from the uterine organs,— to adopt a light, cool, and moderately nourishing diet,— to engage the mind agreeably,— to reside in a dry, airy, moderately warm, or temperate locality,— to take regular but gentle exercise in the open air,— and to have frequent change of scene aud atmosphere. 210. Paracentesis in some instances becomes imperative, owing to the urgency ofthe symptoms, particularly after it has been once performed; and the extirpation of the tumour has been recom- mended by Vander Haar, Delaporte, Mo- rand, Logger, Siebold; and practised by L'Aumonier, Smith, Lizars, Blundell, Granville, M'Dowal and Dieffenbach. Of these measures a brief notice is required.—(a) The observations which have been already offered on paracentesis apply to the treatment of ovarian dropsy even more fully than to any other. It often accelerates a fatal issue by inducing inflam- mation of the sac. Of this I saw a remarkable in- stance many years ago in a near relative. Dr. J. Johnson has adduced an example of it (Medico- chirurgical Review, vol.xi. p. 258.). Dr. Mac- intosh refers to one in his practice (Practice of Physic, vol. ii. p. 374.); and many others have been recorded, and observed by experienced practition- ers. I therefore agree with Dr. Denman, that pa- racentesis ought to be deferred as long as possible. In such circumstances, this Operation occasionally gives temporary relief; but there is a frequently re- curring necessity for its repetition until the patient sinks. It has been proposed to effect a radical cure by evacuating the matter, and either laying open the tumour, or keeping a canula inserted in the wound. Le Dran mentions two cases which recovered from great suffering consequent on this measure; and analogous examples have been recorded by Houston, Voison, and Portal. But these are few compared with the numerous instances in which it has either failed, or accelerated a fatal is- sue by the severe inflammation and constitutional disturbance thereby induced. In two cases in which I was consulted, a canula had been left in the puncture, and rapidly produced these effects; the introduction of air and the mechanical irritation having inflamed the cyst and peritoneum, and con- verted the secretion to a foul, foetid, and ichorous discharge : both rapidly proved fatal. It has like- wise been proposed to inject die cyst. Dr. Den- man mentions a case in which this was practised, but the patient died on the sixth day afterwards. 211. The extirpation of the tumour, although entertained by the older surgeons, was discounte- nanced by Morgagni, De Haen, Sabatier, and Murat. L'Aumonier, of Rouen, however, performed this operation successfully towards the close of the last century; and it has recently been practised by Dr. Smith and Dr. Macdowal, of- the United States, with a like result. Notwith- standing the favourable issue of these cases, I stated, in the Medical Repository, at the time of their publication, reasons against resorting to this measure. The issue of several cases in which it has since been performed, both in this and other countries, confirms the opinion I then expressed. The operation has no chance of succeeding unless it be resorted to during that stage, at which a judi- cious constitutional treatment may either delay, or even remove the disease : and I believe that the cases in which it has succeeded are such as would have terminated favourably if they had been left to nature or to medical management. The results of the cases in which it was performed by Mr. Liz- ars and Dr. Blundell,are well known; and I may add that it has likewise been attempted at least five times at Berlin, by Dieffenbach, Chrysmer, and Martini (Graefe audWAL- ther's Journ. b. xii. h. i.), and, excepting in one instance, it entirely failed. Three of the patients died in consequence of the operation. In one case the surgeon did not proceed in the operation, on finding the tumour adherent on all sides. 212. ii. Dropsy of the Fallopian Tube— Hydrops tubalis— is not to be distinguished from ovarian dropsy; nor, indeed, does it differ from it further than that, instead of the cyst being in the ovary itself, it is developed iu the fold of the liga- ment, near the uterus, or close to the ovarium, or to the fimbriated extremities of the tube; these ex- tremities being either adherent to the ovarium, or 658 DROPSY, ENCYSTED, OF THE WOMB — PERITONEUM — LIVER. closed by coagulable lymph, or adhesions. In ' either case the cyst is solitary. The disease has been described by Dr. Baillie; by Munnik, who found the cyst contain as much as 110 pounds of fluid; by Cypriani, who found 150 pounds; by Harder, who found 140 pounds; and by oth- ers, who have observed much smaller quantities. Dr.GooD defines this variety of dropsy as commen- cing with a heavy elongated intumescence of the iliac region spreading transversely, with obscure | fluctuation ; but no distinction can be made be- tween it and ovarian dropsy, in respect either of ! its causes or progress. The treatment of this vari- j ety is also the same as that of the ovarian disease. 213. iii. Dropsy of the Womb—Hydrome- tra— Encysted Dropsy of the Uterus— has been doubted by some authors : but it has been not in- frequently observed by physicians of the greatest reputation. The cysts which are, in rare instances, found attached to the exterior surface ofthe womb, do not belong to this disease, which consists of a collection of fluid in the cavity of the unimpreg- nated uterus, contained in a membrane or cyst. It has, however, been disputed whether the fluid is thus surrounded, or whether it has accumulated in consequence of inflammation having occluded the os uteri by the deposition of coagulable lymph, or ofthe developement of some tumour or growth, plugging up this outlet; the morbid action which occasions the latter also giving rise to the secre- tion of a great quantity of serous fluid, which ac- cumulates in consequence of this obstruction. It is very probable that this affection may arise from either of these causes, in different cases; and that, in its slighter grades, h is not so infre- quent as some writers suppose,— the dilatation of the uterus, and the pressure of its parietes, over- coming or rupturing the obstruction at the mouth ofthe womb, and causing the fluid to escape. A considerable proportion of the cases vulgarly, but probably correctly, called false conceptions, is of this kind; they seldom becoming the object of medical attention, owing to the little disturbance produced by them, either during their increase, or afterwards, as well as to the deception to which they give rise. Some of these cases may also consist of hydatids, or other mortiid productions, which may be associated with hydrometra, as in cases recorded by Baudelocq.ue, Boivin, Du- ges, and others. (See Ovaria, and Uterus.) 214. iv. Encysted Dropsy of the Perito- neu m — Extra-peritoneal Dropsy — Hydrops Peritonei of Tulfius, and some other authors — consists of the collection of water between the pa- rietes ofthe abdomen and the peritoneum, enclosed in a cyst. It was first noticed by Morgagni, and accurately described by Morand. Twenty- six cases of it have been adduced by Lieutaud, twenty-four of which occurred in females. It pre- sents the same constitutional features as have been noticed in respect of encysted dropsies generally; and although, when the accumulation of fluid is very great, it can hardly be distinguished from ascites, excepting in its early stages, it may ge- nerally be suspected from the less uniform en- largement of the abdomen, the greater anterior prominence of this cavity, its much slower pro- gress, and the less constitutional disturbance; the countenance and surface not presenting the cachectic appearances generally accompanying ascites, and the patient often retaining much vigour and activity of all the natural and animal functions. Still the prognosis in this disease is unfavourable. The sac generally continues to enlarge, and sometimes forms adhesions with the contiguous viscera; and if not evacuated, it event- ually bursts into the cavity of the peritoneum, as in the cases recorded by Chomel (Mem. de l'Acad. Roy. des Scien. an. 1728.), Morgagni (De Caus. et Sed. ep. xxxviii. art. 51.), and Ta- vernier(Lf, Dran's Obs. 65.); or externally,as in those of Degner (Acta Cur. fyc. vol. v. obs. 2.) and La Motte. M. Chantourelle met with a case wherein the sac opened into the intes- tines after a puncture had been made for the dis- charge of the fluid, and faecal matters passed out at the external opening. 215. The treatment of this form of disease has not been satisfactorily illustrated. It seems not materially benefited by purgatives or diuretics; but it is stated, in some instances, to have been permanently removed by paracentesis. And cases have been adduced by Nuck, Degner, Le Dran, La Motte, and others, in proof of the propriety of the practice. But in cases of recovery from a disease of this description, there must still exist doubts of its nature. If puncture be resorted to when the tumour has reached a very large size, the opening should be valvular, and graduated pressure subsequently employed. The terrible ef- fects occasioned by keeping open the orifice in or- der to drain the cavity, were fully demonstrated in M. Chantourelle's case, the cyst having become inflamed, and gangrenous with the ad- joining parts; as well as in two interesting cases recently recorded by Mr. C. Hawkins. 216. v. Encysted Dropsy of the Liver is liable to be confounded with abscess of this organ, or with large accumulations of bile in the gall-bladder, from obstruction of its duct, or of the common duct The cysts which are sometimes found in the substance of the organ, whether of a simple kind, or containing hydatids, are differ- ent from those encysted collections of fluid, which either form between the peritoneum and its prop- er covering, or are apparently attached merely to this viscus. These last evidently consist of bygromatous cysts developed on the adhering sur- face of the serous membrane, and reaching an uncommon size. When large cysts containing hydatids are formed near the surface of the liver, although essentially different from the simple cysts, and seldom reaching the same magnitude, they generally occasion similar symptoms, both local and constitutional, to those which attend the latter. In some instances, these cysts be- come inflamed; thereby occasioning great tender- ness of the external surface, and changing the contained fluid to a sero-puriform matter, as well as increasing its quantity. 217. Encysted dropsy ofthe liver is generally accompanied with more disturbance of the ge- neral health than the other forms of encysted dropsy of the abdomen, and its progress is usu- ally more rapid. Although a dangerous disease, recovery sometimes takes place from it. Cases terminating favourably have been recorded by several writers referred to in the Bibliography. This is most likely to occur if the cyst is attached to the anterior part of the surface of the organ. In this case, a large fluctuating tumour is com- monly formed below the right false ribs, or near DROPSY, ENCYSTED, OF THE KIDNEY. 659 the epigastric region, extending more or less downwards and in other directions, according to its size and situation. Inflammation may take place in the more prominent portion, and the cyst may discharge its contents through an external opening, either made artificially or occurring spontaneously. This latter termination, however, is rare; but it may be followed by recovery; two instances of which are adduced by M. Itard. More frequently the cyst opens into the abdo- minal cavity, or into some part of the alimentary canal, or even into the thorax; and in either case a fatal result generally ensues. In some instances the rupture of the cyst has been occasioned by external violence. The difficulty of distinguish- ing this state of disease from abscess of the liver pointing externally, or from distention ofthe gall- bladder, is always great, or nearly impossible. In both these latter cases, however, there are gene- rally more or less jaundice, more constitutional disturbance or greater pain in the region of the liver, more disorder of the bowels, and more in- terruption to the biliary secretion, than in the encysted collection; the purulent formation being preceded by the usual signs of chronic hepatitis, and distinguished in the manner pointed out in another place. (See Liver—Diseases of.) Interesting cases of this form of encysted dropsy have been published by Mr. Brodie, Dr. Thom- son, Dr. Thomas, Dr. Abercrombie, Dr. Hastings, and Mr.C^ESAR Hawkins. In three of these cases, the early puncture of the tumour, before inflammation supervened, seemed to have been successful. But in nearly all the instances on record, where this operation was performed in a far advanced state of the disease, or when in- flammation ofthe cyst was present, a fatal termi- nation has occurred. 218. vi. Encysted Dropsy of the Kidney is sometimes observed as a consequence of obstruc- tion of the ureter, the pelvis of the organ becoming distended, and the glandular substance either atrophied or absorbed as the accumulation of fluid and distension are increased. This is evi- dently the manner in which the largest collections of fluid are formed in the kidneys, and interesting cases of it are recorded by Bonetus (Sepulchre- turn, 1. iii. sect. xvii. obs. 22.), and by Dr. Howison and Dr. J. Johnson (Medico-Chirurg. Review, vol. iii. p. 657.). In this state of disease there have been observed great irregularity in the appearances, and in the excretion of the urine. The abdomen has been very much enlarged, chiefly towards the side of the diseased kidney, with obscure fluctuation and severe pain in the spine and lumbar region. Simple cysts may also be developed in the substance of the kidney, and contain a limpid or yellowish fluid. They are generally of small size, but occasionally they are found very large. Portal describes one which contained a pint of clear fluid; and M. Itard another, in which there were found two cysts, the larger of which was a foot in diameter. This communicated with the pelvis of the viscus, the structure of which was absorbed, and con- tained a fluid of a urinous odour and colour ; and most probably originated, as in Drs. John- son's andllowisoN's cases, in obstruction ofthe ureter. This species of encysted dropsy generally terminates unfavourably in a shorter time thau, perhaps, any other, probably owing principally to the serious consequences always arising from an interruption to the urinary secretion. In an in- teresting case, which occurred to Dr. Seymour, and is described by Mr. C. Hawkins, a single cyst was found in the substance ofthe kidney, un- connected with its pelvis, and containing five pints of fluid, not possessing any urinous characters. 219. vii. Encysted dropsies of the omentum, of the mesentery, and of the spleen, are of rare occurrence, and can seldom be distinguished from some other diseases during the life of the patient. When fluid is found in the omentum, it is gene- rally effused, or infiltrated between its laminae. But simple cysts, containing a watery or serous fluid, of various sizes, are, in rare instances, found in these situations. 220. viii. Encysted Dropsy is very rarely seen in the thoracic cavity. Haller observed it between the pleura and intercostal muscles, this membrane having become so distended by the fluid as to occupy nearly all that cavity of the chest; the pericardium being also filled with water. Stoerck relates a case in which a female with consumptive symptoms experienced great diffi- culty in lying on the left side. On dissection, a large simple pellucid cyst, formed in the substance of the right lung, and containing eight pounds of a yellowish serum, was detected. Maloet found, in a person with all the symptoms of hydrothorax, and who was obliged always to sit up, a similar cyst, but not so large, in each lung; and the same productions have been observed by M. Dupuytren, in this situation, and in the pericardium. Bibliog. and Refer.— i. Encysted Dropsy gene- rally.—Merclinus. De Hydrope Saccato. Altd. 1695.— Duverney, Mem. de l'Acad. de Scien. de Paris, 1703, p. 178. —Morgag.i, Epist. lxv. art. 16.—Slevogt, De Infelici Hydr. Saccati Curatione. Jenae, 1721.—Scheffer, Hist. Hydr. Sac- •cati. Altd. 1724.—Mead, Monita et Praecep. Med. cap. 8.— Bresl. Samml. 1728, p. 873. (Case containing 163 lbs. of fluid.)—Meckel, in Hist, de l'Acad. de Berlin, 1758, p. 58.— Le Dran. in Mem. de l'Acad. de Chirurg. t. ii. p. 431.—De Haen, Rat. Med. t. iv. p. 71., t. v. p. 55., t. xi. p. 272.— Stoerck, Ann. t. i. p. 149.—Eisenlohr, De Hydr. Cystico. Arg. 1784—Hautesierck, Recueil, t. ii. p. 360.—Vall'isneri, Opera, vol. iii. p. 27 I.—Winship, in Mem. of Med. Soc. of Lond. vol. ii. No. 32.—Lowdell, in Ibid. vol. iii. p. 594.— Hebenstreit. De Hvdr. Saccato. Lips. 1792.—Langenbeck, to Goet. Auz. 1812", p. 19. ii. Encyst :d Dropsy ofthe Ovaria, Uterus,kc.— Blancard, Anat. Pract. cent. ii. obs. 98.—Bonet, Sepulchret. 1. iii. sect. xxi. obs. 47. 70. 77.; N. Act. Nat. Curios, vol. V. obs. 69. (Exthpation proposed.)—De Graaf. De Mul. Or- e;anis p. 160.—Sloane, in Phil. Trans. No. 252.—Short, in Ibid. No. 381. 446.— Morgagni, De Sed. et Caus. Morb. ep. xxxviii. art. 69, 70., xlvii. art. 12.—Werlhof, Opera, iii. p. 771.—Paisley. Edin. Med. Essays, vol. v. part ii. p. 766.— Morand, in M6m. de l'Acad. de Chirurg. vol. ii. p. 455.— Harder, Apiar. obs. 87, 88.—Haller, Disp. Med. vol. iv. p. 401. 447. 541.—Lieutaud, Hist. Anat.t. i. p. 357.—Baude- locqixe, L'Art des Accouch. 1694.—Dc Haen, Rat. Med. pars v. c. 2., vi. 38., vii. 117., xi. 281.—Monro, Edin. Es- says, vol. vi. p 41)9.—Meckel, in Mem. de l'Acad. de Ber- lin, 1758, p. 63.—W. Hunter, Med. Observ. and Inquir. vol. ii. p. 41.—Murray, De Hydr. Ovarii. Ups. 1780.—Sandi- fort. Mus. Anat. vol. ii. tab. 109. — Walter, in Nouv. Mem. df l'Acad. a Berlin, 1786, p. 106.; and Anat. Mus. vol. i. p. 269.—Ford, in Med. Communications, &c. vol. ii. No 14.— Murtineau, Philos. Trans. 1784. p. ill.—Stoll, Rat. Med. vol. vii. p. I5—Camper, in Mem. de la S c de Med. 1788, p. 46.—French, Mem. of Med. Soc. of Lond. vol. i. p. 234. —Walker, in Ibid. vol. v. No. 41— Pulteney, in Ibid. vol. ii. p. 265.—Percival, iu Trans, of Phil. Soc. of Philadelphia, vol. i. p. i.; and Essavs, vol. ii. p. 166.—Denman, Med. and Phvs. Journ. vol. ii. p". 20.—Bosch, in Ibid. vol. viii. p. 444. —Por.al, Cours d'Anat. Med. t. v. p. 551.—Thomann, An- nates Instit. Mid. Clin. Wirceb. vol. i. p. 139.—Muller, in Siebold's Samml. Chiruri:. Beobacht. b. iii. p. 440.—Baillie, Se ies of Engravings, &t. fasc. ix. pi. 6.—Petit, in Bullet. de la Faculty de Med. 1812, p, 3.—Edwards, in Edin. Med. and Surg. Journ. vol. xiv. p. 351.—Voisin, l.ecueil Period. 660 DROPSY IN THE HEAD —Pathology of. t. xvii. p. 372.—Stark, Archiv fur Geburtshiilfe, b. i. st. 1.— ] Osiander, Neue Denkwiirdigkeiten, b. i. St. 2. p. 198.—J. P. Frank, De Cur. Horn. Morb. 1. vi. pars i. p. 311. 317. and | tf§.—Loeffier, in Hufeland's Journ. der Pr. Heilk. b. xxiv. st. 4. p. 42.—Rostun, in Nouv. Journ. de Med. t. iii. p. 215. (7'Ae diagnosis of.)—Chevalier, in Med.-Chirurs;. Trans. vol. iii. p. 40.—Merriman, in Ibid. p. 47.—Thomson, in Ibid. vol. xiii. p. 170. (Hydrometra.)—Thomas, in Ibi I. vol. xiii. p. 330.—Strambio, Nouv. Biblioth. Med. t. iii. 1826, p. 287.—Cuveilhier, Anat. Pathol, livr. v. pi. iii.—Delpech, Chirurg. Clinique, t. ii. p. 192.—Andral, Anat. Path. t. ii.— Lizars, Observ. on Extraction of diseased Oiaria, fol. Edin. 1825.—Julia-Fontanelle, Archives Gene>. de Mid. t. iv. p. 28T. (Analysis of the fluia.)—Smith, in Med. and Phys. Journ. Oct. and Nov. 1822—Burns, Principles of Midwife- ry, 6th ed. p. Li2.—Nauche, Des Malad. propres aux Fem- mes, 8vo. Paris, 1829. p. 164.—Hamilton, On Mercurial Medicines, p. 202.—Seymour, On Diseases of the Ovaria, fol. Lond. 1830, p. 43. tt seq.—Boioin, Rech. sur l'Avortement, p. 103. 131.—Dance, in Archives Gin. de Med. vol. xxi. p. 214.—Dieffenbach in Ibid. t. xx. p. 92.; et Journ. Hebdom. de Med. 1829, t. ii. p. 246.—Mme. Boivin et A. Duges, Traits Prat, des Malad. de I'Uterus et de ses Annexes, &c. 8vo. Paris, 1833, t. ii. p. 520.— Elliotson, in Medical Ga- zette, vol. viii. p. 291., and vol. xii. p. 454.—C. Hawkins, in Ibid. vol. xii. p. 458. iii. Of the Peritoneum and Abdominal Parietes. —Vander Wiel, Observ. cent. ii. obs. 28.—Anhornius, Ephem. Nat. Cur. cent. ix. obs. 100. n. 2.—Tulpius. 1. iv. c. 44.—Rhodius, cent. iii. obs. 6.—Garengeot, i. p. 435.— Morgagni, De Sed. ice. epist. xxxviii. art. 47. 49. 53. 58.— Chomel, Mica, de l'Acad. des Scien. de Paris, 1728, p. 16.— Littre, in Ibid. 1707, p. 667.—Watson, in Philos. Trans. No. 201.—Buchner, Miscell. 1728, p. 871.—Monton, in Mem. de l'Acad. de Chirurg. t. ii. p. 445.—Blasius, Obser. Med. Rarior. pars i. No. 18.—Vogel, DeHydr. Peritonei Saccato, Sec. Goet. 1761.—Lieutaud, Hist. Anat. Me.l. 1. i. obs. 1724. —Sandifort, Exercitat. Acad. 1. ii. c. 10.—De Haen, Rat. Mel. pars xi. c. 4.—Allen, Synop. Med. Pract. p. 294.— Van Swieten, ad § 1226.—Porcherie, Journ. de Mid. t. x. p. 422.—Portal, Anat. Med. t. v. p. 128.—Jacquin, Med. Observ and Inquir. vol. i. p. 7.—Horn, De Hydr. P.ritonaei Sac. Giess. 1790.—Mliiler, in Posewitz's Journ. fur die Medicin, kc. hef. i. n. "i.—Hufeland, Journ. d. Pract. Ar- zeneyk. b. viii. p. 116.—Selig, in Ibid. b. iii. p. 271.—Bro- die, Load. Med. Gaz. vol. i. p. 334.—Thomson, in Ibid. vol. i. p. 468.—Abercrombie, On Dis. ofthe Stomach, kc. p. 356. —Hastings, Midland Med. Reporter, Aug. 1829.—Chantou- relle, De l'Hydr. Enkystee de Paroi, Abdoin. kc. ; in Ar- chives Genir. de Med. t. xxvii. p. 218.—Dance, in Diet, de Med. 2d id. t. i. p. 113.—C. Hawkins, On Aqueous Encyst ed Tumours, &c, in Trans, of Med, Chirurg. Soc. vol. xviii. p. 98. (An able and instructive paper.) iv. Of the Liver.—Donatus a Mutiis, In Galeni Inter- pretationes, &c. 1547.—Alix, Observat. fa,— as its cause (De Morbis, lib. ii. cap. 15. edit. Vander Linden, t. ii. p. 47.). From Hippocrates to Rhazes, no mention is made of internal hydrocephalus. But this latter writer states, in his book on the diseases of children, that the head sometimes acquires an increased bulk, owing to the collection of fluid within the cranium. The chronic form of this malady was described nearly a century before any notice was directed to its acute states; but, during the last fifty years, these states have attracted attention great in proportion to their prevalence and fatality in the early stages of life. i. Acute Dropsy in the Head.—Svn. Hydrocephalus Acutus ; H. Acutus internus; Hydrencephalus(from i'cV«>, water, and tyyeipu- Zoc, the brain); Febris Hydrocephalia; Cams Hydrocephalus; Apoplexia Hydrocephalica, Cullen; Hydr encephalon, Hufeland; Hydrops Cerebri Acutus; Hydrocephaly aigu, Fievrt Cerebrate des Enfans, Auct. Gall.; Hydroc6- phalite, Brachet. 225. Defin. — Fever, with sopor headach, and morbid sensibility to light, fyc; inability to bear the erect posture ; vomiting ; costiveness ; screaming ; dilated pupils ; squinting ; convul- sions and paralysis. DROPSY, ACUTE, IN THE HEAD —History of. 661 226. Lit. Hist. — Acufe hydrencephalus, not- withstanding the remark of Hippocrates already referred to, was formerly confounded with cere bral fever, or fever with determination to the brain. A case, in which it is accurately de- scribed, but considered as one of fever merely, was published by Dr. St. Clair, in 1733, in the Edin. Med Essays and Observations, vol. ii. p. 287. Mr. J. Paisley, of Glasgow, in the fol- lowing year (in Ibid. vol. iii. p. 333.), recorded a case, with the post mortem examination, and first recognised it as a specific form of disease. It was not, however, until the appearance, in 1768, of Dr. Whytt's " Observations on the Dropsy of the Brain," that the history ofthe malady and its nature were made subjects of investigation. The observations of Dr. Fothergill (Med.Observ. and Inquir. vol. iv.) contributed something to the knowledge of its symptoms; but those of Dr. Watson, in the same work, furnished evidence merely of its extreme danger. Dr. Dobson's case, published ia 1773 (Ibid. vol. vi.), was val- uable, inasmuch as it showed the possibility — at the time, very generally doubted — of curing the disease; and of the influence of mercury in bringing about this result. Harris, however, had long before stated, as Dr. Cheyne has re- marked, that a physician of experience had saved children in fevers attended by unusual stupor, and even coma, by giving them mercurius dulcis, six times sublimed. 227. The opinion of Whytt, that the disease depends upon laxity of the exhalants, or upon a watery state ofthe blood, had been generally re- ceived, until Dr. Q,uin, in 1779, maintained that it is allied to inflammation, — a doctrine which had suggested itself to both Dr. Withering and Dr. Rush, before Dr. Q,uis's views had become known. Dr. Withering stated explicitly, that the malady originates in inflammation, and that the water found in the ventricles of the brain is not its cause, but its consequence. Dr. Rush made an important addition to its history, by showing that it may be produced by other dis- eases, especially by fevers, rheumatism, pulmo- nary consumption, the exanthemata, and worms; and that death may supervene, preceded by hy- drocephalic symptoms, and little or no water be found in the ventricles, — circumstances which will be fully enquired into in the sequel. Dr. Percival demonstrated its frequent connection with scrofula, and seemed impressed with the idea that it is not altogether identical with in- flammation in its nature. Its inflammatory origin was afterwards supported by Dr. Patterson and Dr. Garnett, although neither appeared to con- sider it advisable to carry the depletory and anti- phlogistic treatment so far as such a doctrine might have warranted. This last writer believed that, in hydrocephalus, a local inflammation with- out much general sthenic diathesis obtains; and that a depletory treatment, injudiciously em- ployed, may weaken the general tone of the sys- tem, and increase the effusion, without materi- ally diminishing the local morbid action, for the removal of which such means are employed. Of the justice of this view there can be no doubt. The local action, which has been called inflam- matory, merely because it is attended by injec- tion of blood-vessels, has been too generally treated as true inflammation occurring in a 56 healthy constitution, and without reference either to the series of vessels affected, or to the grade, or the product of action; and, what is equally important, without regard also to the diathesis, or state of vital manifestation and power. It is unnecessary to notice here the opinions of more recent writers, as the chief of them are referred to in their proper places. 228. Descriptive History. — The Precur- sory or Early Symptoms of acute hydrocephalus | are remarkably diversified, owing to the circum- stance of their dependence upon disorder of the di- gestive organs, or of the circulation in the brain and membranes: and it is chiefly owing to the predominance of the symptoms referrible to one or other of these parts that the disease has been divided by some writers into the primary or idio- pathic, and the secondary or symptomatic. The possibility, however, of making the distinction in practice is not so easy as some writers would make it appear. For the dependence of the functions of the liver, and digestive organs, upon the state of circulation in the encephalon, and of the latter on the former, is so very intimate, that it is often impossible to ascertain which is primarily affected. The majority of writers on the disease iu this country consider that the diges- tive organs are the first to betray disorder; whilst the French pathologists and Dr. Abercrombie believe that the morbid action very frequently commences either primarily or simultaneously in the brain itself. I am convinced, that the true acute hydrocephalus originates more frequently in the encephalon, than the abdominal functions indicate, and at a period anterior to the disorder which these functions manifest, — such dis- order often proceeding from the silent morbid action in the brain, reacting on it, and promoting the evolution of those changes constituting the disease; and that, when hydrocephalic symptoms supervene more suddenly and violently, and with- out much previous disorder of the chylopoietic viscera, or nervous system, they have a more intimate relation to acute or sub-acute inflam- mation of the brain and its membranes, than to those states of morbid action which terminate in copious effusion, and to which the term hydro- cephalus is more strictly applicable. The chief exceptions to these inferences will be found in those who inherit a peculiar morbid diathesis or predisposition to the malady — who are scrofu- lous or weakly constituted, — and in these the brain and its membranes will often coetaneously suffer, in a greater or less degree, with one or more of the digestive organs; the excited action it experiences being either attended, or soon fol- lowed, by deficient power, and by relaxation of the exhaling surfaces. In these cases, as well as in those in which it is ushered in, or predis- posed to, by derangements of the abdominal vis- cera, it does not, as in true cephalitis, readily occur in a previously healthy constitution, but chiefly in states of pre-existing ailment, or as a consequence of inflammatory action arising under such circumstances, — in which not only the chylopoietic viscera imperfectly perform their functions, but also the organic nervous system ' is weak, and the capillary vessels and exhalants | are so deficient in tone as to be readily relaxed, or exhausted when over-excited. In other words, I that acute hydrocephalus is a consequence of fiO 662 DROPSY, ACUTE, IN THE HEAD —Forms, etc. of. disease, which originates variously; — in some it is the result or termination of inflammatory action occurring in a weak or morbid state of consti- tution, — in others of general febrile excitement, affecting patients similarly constituted, or occa- sioned by accumulated morbid secretions and excretions, or by local irritation; — that it stands in the same relation to inflammation as other acute dropsies; and, even when most inflammatory, that it differs from encephalitis much in the same way as phlegmon differs from erysipelas, or as acute peritonitis differs from the true puerperal fever. From what I have now stated, it will appear important to be acquainted with the symptoms indicating the pathological states ter- minating in acute hydrocephalus. These may be referred to two principal seats, viz. the head and the abdomen, but with the understanding that, in many instances, although the more distressing ailments seem to proceed from the one, the pri- mary and principal disease may exist in the other. 229. Forms and Stages of the Disease. — (a) The Forjns have been chiefly referred to the mode of attack and symptoms of the first stage. Dr. Cheyne has particularised three varieties; the gradual, the sudden and violent, and the sec- ondary. These answer to the nervous, the in- flammatory, and the consecutive, respectively, of Hopfengartner and Kuhn. Guersent di- vides the disease into the ataxic or febrile, and the apoplectic; Itard, and several writers, into the idiopathic and symptomatic. M. Brachkt de- signates three forms; the nervous hydrocephalitis, the inflammatory, and the gastric; but it is very difficult to distinguish the nervous from the gastric form. Goe lis distinguishes merely the acute, and the hyper-acute or waterstroke. The division re- commended by Cheyne and Hopfengartner is, upon the whole, the best; it matters but little how the forms are named. The terms, however, used by the German writers seem to be the least objectionable — (b) Since the appearance of Dr. Whytt's description, the disease has usually been divided into periods or stages. But much differ- ence has existed as to the number of stages, and as to what symptoms indicate them. Goelis points out four periods, viz. of turgescence, of inflamma- tion, of effusion, and of palsy. Whytt, Quin, Tissot, Baader, Sprengel, Cheyne, and others, mention three, according to the three differ- ent states of the circulating and nervous systems that obtain in the course of the malady. Some writers notice, with P. Frank, Rush, and Con- radi, only two stages; whilst Formky, Von PoRTENScHLAG,and Guersent describe none. This diversity depends chiefly on the irregular progress of the disease, its uncertain commence- ment, and the circumstances referrible to the constitution and previous health of the patient under which it occurs. I shall adopt the divis- ion, employed by Dr. Cheyne and others, into — 1st, that of increased sensibility; 2d, that of diminished sensibility; and, 3d, that with palsy or convulsions. 230. A. The Nervous form is generally pre- ceded by, or rather commences with, a great va- riety of symptoms, which continue a longer or shorter lime before the disease is so fully deve- loped as to be recognised, or as to excite the attention or alarm of the friends. For several days or weeks, or even for months, the child is vertiginous, liable to fall or stumble while at play or running about, is nervous, and starts or is fearful from slight causes, and more or less ca- pricious in its appetite, or without appetite. The tongue is slightly furred, and white; the bowels are costive; the motions offensive, unnatural, clay-like, and indicating a morbid or deficient biliary secretion; the breath is fcetid; the urine is somewhat diminished in quantity; the com- plexion fades; the features collapse; the sleep is disturbed and dreamy; the eyes become heavy, very sensible to light, have a dark line under them, and lose their animation; the hypochon- dria and abdomen are often tender or tumid; and the child complains of occasional pains, which resemble rheumatism, in these regions, particularly in the region of the liver, and some- times in the limbs. Various other symptoms are conjoined to, or supervene upon the foregoing, which continue frequently for a considerable time, without additional ailment, or confining the pa- tient. But sooner or later they become aggra- vated; the surface assuming a harsh, sallow, or unhealthy aspect. The movements are now lan- guid; the sleep more and more disturbed and unrefreshing, and the disposition to it often greater. Giddiness^ slight pain or noise in the head, tenderness of the scalp, and pains in the neck and' limbs, are complained of. The coun- tenance is heavy; the sense of sight and hearing often very acute; and the pulse is quicker, and more excitable than natural. The child is drowsy, silent, or appears as if in a reverie, and indifferent to those persons and objects he was formerly interested in. He is also irritable, or dejected, sighs often, and yet frequently makes no complaint, when questioned. Purgative me- : dicines usually procure scanty, clay-like, pale, or greenish and slimy evacuations. These symp- toms are very frequently removed by active purg- atives; and although they often run into those indicating unequivocal disease within the head, I yet they indicate nothing beyond a general and grave disturbance of the functions. But when they persist after proper treatment, or are neg- lected, the first stage may be considered as being actually present, although it should be rather viewed as commencing with the first signs of ailment; more pathognomonic symptoms su- j pervening on the foregoing indefinite ailments. ! The above series of symptoms nearly agrees with the first period, or that of turgescence, of j Goelis. 231. (a) The pain in the head returns more frequently and acutely; and is often attended by j severe ear-ache, by aching of the eyes, and more i commonly by increased sensibility to light and noise, and alternate chills and flushes. The pulse is now quick, excitable, and of irregular strength and frequency. The gait is unsteady; the skin warm, dry, and unhealthy; the pains through the trunk and limbs more frequent and severe, and accompanied with sickness and vo- miting, particularly on getting up in the morn- ing. The tongue is loaded or furred. There is occasionally dragging of one leg, or a raising of the foot as if stepping over something in the way, or a painful crick in the neck. The stools, from being scanty, costive, and clay-like, pass to dark green, and a gelatinous or spinach-like state, ex- hale a sickly and peculiar smell, and are still DROPSY, ACUTE, IN THE H procured with difficulty, this change depending chiefly upon the morbid condition of the secre- tions poured into the digestive canal: the urine is scanty and turbid, and has often a milky appear- ance (ODiER,CoiNDET,and Vieusseux). The erect posture or motion, particularly rotating the head, brings on sickuess and retchings, without- the appearance of offensive matters. There are also great fretfulness and restlessness; contracted pupils; frowning, or knitting of the brows; in- ability to sit up; a whining or moaning noise when lying down; and sometimes a slight cough, with irregular suspirious breathing. The sleep is short and restless; the infant rolls its head on the pillow, or often wakens with a scream or crying, and raises its hands to its head. The nos- trils and lips are dry and cracked. This period is very variable in duration, but it usually contin- ues from ten to fifteen days. 232. (b) Second stage.—The pulse, from being very quick, excitable, irregular, and weak, now becomes slower — sometimes as slow as natural, or even more so; but chiefly when the patient is in the horizontal position; for if he attempt to sit up, it generally acquires its former frequency. The sensibility is now remarkably impaired : so- por or stupor gradually supervenes, with dilated pupils, squinting, and imperfect or double vision. The eyes are dull, heavy, vacant, or staring; the eyelids drooping or half closed. Sickness or retchings are now less frequent, unless the child be raised up, when one or both often occur. The excretions are passed unconsciously, and are scanty, and procured with difficulty. The stupor is interrupted by exclamations, or shrill piercing screams; the hands, which are tre- mulous, being raised to the head or neck, or occupied in picking the lips or nostrils. Emaci- ation proceeds rapidly; but food is generally swallowed greedily when presented. These symptoms are, however,.by no means uniform; for the pupil is frequently, particularly at first, oscillatory, or, although dilated,-affected by light. The stupor, also, is not always constant; nor does the pulse always become slow. Deep in- spirations, hectic flushings of the cheeks, cold extremities, low delirium, and an almost total suppression of urine, are occasionally observed. The duration of this period varies from four or five days to two weeks. 233. (c) The third stage has been generally recognised by the returning frequency of pulse, which is often remarkably rapid, thready, and weak; by the occurrence of general or partial convulsions; by paralysis of one side or limb; by twitching of one or more of the muscles; and by suffusion of the eyes, the eyelids being mo- tionless, and the cornea becoming dim and filmy. Often, when one side is paralysed, the other is more or less convulsed. The patient is now either insensible or delirious. He rolls his head on the pillow, grinds his teeth, moves the un- palsied hand in the air, and moans or breathes heavily and hurriedly. Alternate flushings and pallor, or flushes of one cheek, the other being pale; irregular distribution of the circulation ; partial sweats ; cold extremities ; irregular, or stertorous breathing ; an eruption of vesicles about the mouth, or on the face and upper part of the chest (Formey, Goelis, Schmalz, Raimann. and myself); collapse of the counte- [EAD—Forms and Stages of. 663 nance; blueness or paleness of the lips; and, more rarely, sphacelating sores; are remarked towards the close of the disease. The dilatation of the pupil and strabismus generally continue through- out this stage, which may terminate fatally (gen- erally in a violent convulsion) in a few hours, or it may last for ten or twelve days, or even longer. Such is the common course of the most frequent form of the disease, which comprises the Nervous and Gastric of Brachet; and which may either originate in the encephalon, or in the digestive organs. But it is seldom that the early history of the case is so precise as to enable the physician to draw a correct inference as to its commence- ment. - In some instances, I have observed slight symptoms of cerebral disease, for some weeks, or even months, after repeated attacks of con- gestion or of inflammatory action within the head, of a well marked character, but supposed to have been removed by treatment. In some of these cases, the disorder of the digestive organs was so evident as to give rise to the idea of the primary affection of these viscera, indicating the difficulty of ascertaining the parts first deranged. The information furnished, in most instances, seldom enables us to carry our pathological analysis suffi- ciently far back to connect the early ailments with their causes; and, consequently, we often fail in ascertaining the quarter where disease commences. 234. B. The Inflammatory variety, or the second form of Dr. Cheyne, of M. Coindet, and of Hopfengartner, is more acute than the preceding. The precursory symptoms are generally of short duration, and sometimes sq slight as to be overlooked. This variety nearly resembles fever, with predominant affection of the head; and in many cases it is not to be distinguish- ed from inflammation of the brain and its mem- branes (see Brain, § 174. etseq.), the disease being merely a modification of inflammatory ac- tion, depending upon diathesis, and previous state of health; and, owing to these circumstances, giv- ing rise to effusion. After the child has been drooping for a short lime, fever, with slight, short, and irregular remissions, flushings, severe head- achs, increased heat and sometimes soreness of the scalp, augmented sensibility, thirst, hot skin, brilliancy of the eyes, and tenderness over the abdomen, supervene; the pulse being rapid, hard, or small; and the tongue white or loaded. Stupor or unwillingness to be roused, alternating with violent screams, and complaints of the head and belly; great irritability of the stomach; retching readily brought on by changes of position or by sitting up; a morbid and scanty state ofthe alvine evacuations; a vacant, dejected, or heavy expres- sion of the eyes; a pained and terrified look; and diminution of all the secretions and excretions; commonly characterise this form of the malady. This first stage is usually accompanied with many of the phenomena of the first period of the fore- going variety: the chief difference being in the more febrile condition of that now under consid- eration, in the earlier and more evident connection ofthe symptoms with the brain, and in the short- er continuance of this stage. As soon as the changes which attend the second period, viz. di- lated pupils, strabismus, stupor, diminished fre- quency of pulse, &c, appear, the progress of this Is in all respects the same as that ofthe first variety; 664 DROPSY, ACUTE, IN THE HEAD —Remarks on. the stages being more distinctly marked, but fre- quently of shorter duration, than in it. This form is generally idiopathic, whilst the foregoing is often symptomatic of disease of the liver and digestive organs. 235. C. The Consecutive variety is observed in an advanced stage of some acute disease, or soon after its decline, assuming either of the fore- going forms. It may follow the disappearance of some scrofulous affection; in which case it gener- ally presents the characters ofthe first variety. It may come on after scarlatina or measles, and early in hooping cough; and it then commonly makes its attack with all the violence of the second variety. When it appears during remitting fever, difficult dentition, and in the latter periods of per- tussis, it often steals on so imperceptibly, as not to be recognised until dilated pupil, strabismus, convulsions or paralysis, and other symptoms of" the advanced stages, are remarked. In such cases, the symptoms ofthe early period are liable to be confounded with those of the malady of which it is consecutive. Pain, which is one of the most prominent features of hydrocephalus, is sometimes but little felt in this form. 236. Remarks.—The varieties now pointed out can be recognised only during the first stage, and chiefly by the mode of attack, which, in the first, is always slow and insidious. This is the most fre- quent form of the disease. In the second, the at- tack is more sudden and tumultuous; its first stage lapsing into the second in from two to four or five days. This, however, is the least frequently ob- served in practice, and is hardly to be distinguish- ed in its first stage from inflammation of the brain and its membranes, of which it is only a modifiV cation or termination, when affecting the more central and internal parts of the encephalon. It occurs in more healthy children than the other forms do, and is commonly idiopathic or primary. The third variety often proceeds not only insidi- ously, but rapidly; and is generally the most fatal. It may present very unequivocal inflammatory characters in some cases, particularly when it fol- lows the exanthemata; and in others, neither the symptoms, nor the appearances upon dissection, of true inflammatory action, may be observed; as when it is consecutive of hooping cough, remit- tent fever, and other affections, chiefly referrible to the digestive organs. During the progress of all the forms of the malady, especially the first and third, the febrile symptoms are very irregular, and often only occasionally present. The thirst and appetite are also various; and the breathing is sometimes calm and soft, and, at others, laborious, quick, and suspirious. The circulation is at times irregularly distributed, the head being hot and the cheeks flushed, while the lower extremities are cold; and at other times it is more equable, the countenance being pale, the skin warm, and even perspirable throughout. The bowels are generally as already described; but, in some cases, a bilious purging attends the vomiting. In a few instances, after the delirium, insensibility, and convulsions in the last stage, a return of the senses and intel- lect has ushered in dissolution. 237. In young infants, hydrocephalus is ascer- tained with much difficulty, and is liable to be confounded with disorder of the digestive organs. The knitting of the brows, watchfulness, moaning, feverishness, the throwing back of the head, start- ing from sleep with a cry of alarm, frequent vom- iting, aversion from light, the peculiar character of the stools, the half-closed eyelids, the full or distended fontanelle, and hanging or rolling ofthe head on the nurse's arms, are the chief symptoms. The expression of pain is not violent at this epoch; and there are not, in this disease, the drawing up and flinging out of the legs, with screaming and crying, as in colic or griping pains. It seldom, however, appears before the period of dentition; but, when it occurs about this period, it is often ushered in by convulsions, or convul- sions appear at an earlier stage of the malady than in older children. 238. The duration of acute hydrocephalus is extremely various. When it has reached the second stage, its duration is very uncertain; for death may supervene in a few hours, or not until after two or three weeks. In young infants, it frequently advances most rapidly. Fothergill, Coindet, Sprengel, Cheyne, Goelis, &c. consider that it commonly runs its course within three weeks. Whytt, Frank, C. Smyth, Yeats, and others, believe that it may be pro- tracted much beyond that period. The consecu- tive form may terminate in about a week; and the inflammatory seldom lasts longer than three weeks; but the first or nervous variety may con- tinue for four, five, or even six weeks, or longer, if the earliest symptoms be taken into the account. In some instances, especially of the first form,the disease may assume a nearly chronic character, or a state intermediate between the acute and chronic, or may pass altogether into the latter, especially in young children; a slight separation of the sutures, enlargement of the head, sallowness, marasmus, palsy, &c. taking place; and a larger collection of fluid being found in the ventricles than in the more acute states, although less than in the con- genital and chronic. The most common duration of the disease, according to my experience, is from two to four weeks. There is great difficulty, as respects the first and third forms particularly, in determining the period at which the malady giving rise to the effusion begins. As to the effusion it- self, it may commence coetaneously with the sec- ond stage, or not until a subsequent period. 239. Appearances on dissection vary remark- ably, even in cases belonging to the same form of the disease.—(a) In the first form, the veins of the membranes are generally found congested, with dark-coloured blood. In a few instances, I have observed inflammatory appearances in the longitudinal sinus; and a similar observation has been made by Bucholz. The ventricles usually contain from two to six or eight ounces of limpid serum. The substance of the brain is soft and blanched, especially towards the central parts; and in the vicinity of the ventricles it is often very much softened, the fornix and septum luci- dum being more or less disorganised, and soft like curd. The choroid plexus is pale, sometimes granulated. The pituitary gland is occasionally infiltrated, or otherwise slightly altered (Mor- gagni and myself); a slight watery infiltration of the substance of the brain has also been noticed. Tubercular formations have been found in various situations within the cranium (La e n n f. c,Me rat, &c). Several other slight lesions of the encephalon have been observed; but they are by no means constant, and may be viewed as merely contin- DROPSY, ACUTE, IN THE HEAD —Grades of. 665 gent changes. The liver is often inflamed, some- what enlarged, and extensively adherent to the adjoining surfaces. Dr. Cheyne has remarked small white tubercles on the surface of this organ; and I have seen them in this and other parts of it, as well as in the spleen. The mesenteric glands are frequently enlarged, and contain caseous de- positions. The stomach and intestines are some- times inflamed, the latter constricted, and even intus-suscepted. The mucous follicles of the digestive canal are often enlarged. 240. (6) In the second, and in most of the third, forms ofthe disease, the brain and its mem- branes, particularly towards the base and central parts, present many of the usual appearances of inflammatory action, especially injection of the vessels, and thickening and opacity of the mem- branes, in addition to effusion of serum. The fluid is not so generally limited to the ventricles in these forms as in the first, is usually in less quantity in these cavities, but is effused also be- tween the membranes, especially in the general cavity of the arachnoid, or between this mem- brane and the pia mater, elevating the former, and thereby exhibiting a gelatinous appearance. Bonet and Greding observed effusion between the cranium and dura mater; and Dr. Aber- crombie thinks this not a rare occurrence, and that it is the source ofthe fluid which escapes upon opening the head. The fluid itself is much less limpid in these varieties, than in the first; it being often turbid, or whey-like, containing minute shreds of lymph, and presenting evident traces of albumen. In many of the cases belonging to the second form, the cerebral substance retains its consistence, its cut surface indicating increased vascularity. In some cases, the surface of the ventricles is covered by a fine film of lymph, which hardly adheres to it. In several instances of the disease consequent upon scarlatina, I have observed the effused fluid of a turbid, brownish, and sanguineous appearance. 241. D. Hyper-acute Hydrocephalus; ApoplexiaHydrocephalica; Wasserschlag,Germ'.; or Waterstroke.—The sudden effusion of water on the brain, although noticed by some other writers, was first described by Goelis. He states that it may take place either idiopathically, or in con- sequence of various diseases. Although I have met with many cases of its consecutive occur- rence, I have seen none that could be strictly called idiopathic. It most commonly appears in the advanced stages of the exanthemata, after the repulsion of chronic eruptions, as tinea ca- pitis, crusta lactea, discharges from the ears; or after the arrest of habitual evacuations and excretions, as chronic diarrhcea, dysentery, the choleric fever of infants, habitual perspirations, &c., and when the powers of life are much re- duced. In all such instances, it is to be consider- ed merely as a more rapid form of the third, or consecutive, variety of hydrocephalus already described; taking place, in some instances, with surprising suddenness, and terminating fatally with great rapidity— sometimes in from twelve to twenty-four hours. The attack, under these cir- cumstances, is seldom or ever recognised until the symptoms of the second or third stage of acute hy- drocephalus supervene. Goelis supposes, from the appearances of vascular turgescence observed in some cases after death, that a degree of inflam- 56* matory action may suddenly supervene, and be coincident with effusion. But it is very rare that marked vascularity of the membranes and brain of children is not observed upon dissection, what- ever may have been the disease of which they died. It is very probable that increased determination of the circulation has preceded, or accompanied, the effusion in these cases; but the vascularity is no proof of inflammation. The effusion, in the seve- ral instances of this kind that I have examined, was chiefly in the ventricles, although partly also between the membranes; was generally in less quantity than in the common acute disease,— in all the cases, under four ounces; was less turbid than stated by Goelis; and occurred in children who were of an unhealthy habit, lax fibre, and much reduced by disease. 242. E. Sub-acute Hydrocephalus.—This form of dropsy in the head, already alluded to, is deserving of more particular notice, from the fre- quency of its occurrence. I have met with it most commonly as a slighter grade of the first variety described above (§ 230.). It generally occurs be- tween the second month and the commencement of the second year of age. After the continuance of many of the symptoms characterising the first stage of that form, the head begins to enlarge, with slight separation of the sutures, and imper- fect developement ofthe symptoms ofthe second stage. In many cases, the disease is slighter, and the duration longer, than in the first form; but, in others, the symptoms are quite as severe for several days, when the yielding ofthe cranial pa- rietes before the effused fluid seems to abate their violence. In some cases, the malady is prolonged merely for a few days; in other cases, for a much longer period, so that it runs into the chronic. In rare instances, recovery is slowly and insensibly established, the patient — especially if nature be judiciously assisted by art — outgrowing, as it were, the disease. During its progress, the symp- toms vary but little in kind from those already described. The bowels are generally irregular after having been long torpid, and they sometimes become lax, the spools being mucous, unnatural, and offensive. In some instances, diarrhcea comes on during the advanced stages; and if this be not checked, and if the powers of life be supported or promoted, and appropriate remedies prescribed, recovery may take place. But more frequently the loss of flesh, general cachexia, disorder of the bowels, sopor, paralysis, &c. advance slowly, until convulsions or exhaustion terminate life. 243. Dissections.— In all the cases I have ex- amined, the fluid effused was altogether in the ven- tricles, has exceeded eight ounces, and was either entirely or nearly limpid. The brain surround- ing the ventricles was frequently softened; but, excepting a common injection of the membranes, there were no remarkable inflammatory appear- ances in the encephalon. A thin film of mucous lymph covered the surface of the ventricles in some instances. An increased quantity of fluid was occasionally found about the medulla oblon- gata, and in the spinal canal. The liver was often more or less inflamed or enlarged, the di- gestive mucous surface also inflamed in various parts, and Peyer's glands were enlarged — in some cases ulcerated. The mesenteric glands were frequently diseased in the manner stated above (§ 233.). 666 DROPSY, ACUTE, IN THE HEAD —Diagnosis. 244. Diagnosis.— Although the disease is rea- dily ascertained iu its far advanced stages, when it is nearly or wholly beyond the reach of me- dical aid, it by no means admits of easy recog- nition at an earlier period. Indeed, as will be hereafter shown, the effusion being often an oc- currence contingent on a variety of ailments, and often arising out of a morbid condition of the system, and of the parts contained within the cranium, no early diagnosis can be formed; for the functional disturbances and general febrile commotion characterising the commencement of the disease, are readily removed in many in- stances, whilst, in others, apparently as slight, or even slighter, the symptoms commonly attributed to the effusion will rapidly supervene, notwith- standing the most judicious treatment: and, after all, it remains very questionable, whether or not the symptoms commonly attributed to the effusion are not rather the results of the changes which have taken place in the organic nervous influence, in the circulation, and in the structure of the brain, upon which changes the effusion is merely contingent, than the consequences of the effusion itself; for I have observed, in several cases, as much fluid effused within the cranium, there having been no hydrocephalic symptoms during life, as in the most marked form of the disease. We have, moreover, seen that, in many ofthe cases of inflammation ofthe brain, or of its membranes (see Brain, § 175.), very nearly the same train of symptoms appear as in acute hy- drocephalus, and yet little or no effusion takes place; and that, in the more inflammatory variety of this malady, where the symptoms character- ising the advanced stages are most marked and uniform, the quantity of the fluid effused is gene- rally the least. Where, however, we see a child in a state of insensibility, rolling his head upon the pillow, frequently grinding his teeth, scream- ing acutely, moving one hand in the air, while the other is palsied, with a hectic on the cheek, drooping eyelids, heavy vacant stare or strabis- mus, dull filmy cornea, dilatation of the pupils, colapsed features, general emaciation, partial sweats, suspirious, laborious, or rapid breathing, and convulsions, after having been ailing for some time, and more recently affected by febrile action, with marked disorder of the digestive organs and of the head, it may be inferred that effusion has taken place within the ventricles, and at the base ofthe brain, chiefly in the former; but of this there is no complete certainty, for very nearly the same phenomena may arise from exten- sive encephalitis, or from inflammatory softening of the brain, at their most advanced stages. 245.(a) I have already stated that the disease, in its inflammatory form, is nearly related to in- flammation of the brain and its membranes; and I may now add, that, in the first form described, it is often equally closely connected with softening of the organ (see Brain, §214.). In many cases, the distinction is made with great difficulty, and in some it is not to be made at all; for the effu- sion is, in such, merely one of several coexistent changes either immediately consequent upon, or more remotely following, the inflammatory act in the former class of cases, and the softening in the latter. When, however, any diagnosis can be established by the close and experienced observer, it is most important to be guided by it. The tur- ' gescence, which attends inflammation ofthe brain, often gives rise to symptoms which nearly resem- ble those produced by watery effusion: and it is only by estimating the history of the case in con- nection with the causes and a number of existing phenomena, that an opinion can be formed as to the exact state of disease.— a. Encephalitis occurs more frequently in previously healthy children; its attack is sudden, and the progress of its early stage rapid and tumultuous; hydro- cephalus appears in the unhealthy; and consecu- tively either of previous attacks of cogestion or inflammation of the brain, or of disease of the digestive and chylopoietic viscera,— generally in a gradual, slow, or insidious manner : the former being commonly an idiopathic, the latter often a symptomatic disease.— . In encephalitis, pain is constant and throbbing, increased by any ex- citation of the circulation, frequently preceded, or attended, or followed, by distinct chills or rigours : in hydrocephalus, pain is intermittent or remittent, shoots with great violence, occasioning anguishing screams, wants the pulsating charac- ter, is not increased by what excites the circu- lation, often alternates with pains in the abdomen, and is seldom attended by chills or rigours.— y The sickness and vomiting, symptomatic of the former, are unaccompanied by the fulness and tenderness of the hypochondria and epigastrium which commonly precede and attend these symp- toms in the latter malady.— q. The counte- nance in encephalitis is tumid and injected, the features enlarged, the attendant fever of a sthenic or phlogistic character, and its progress very acute : in hydrocephalus, particularly its first and most common form, the countenance is not very sensibly tumid; the cheeks only are irregularly flushed; the thirst is not so great, nor the anorexia so complete; the febrile heat is not so high, so general, or so constant ; the surface is not so full and animated, nor is the pulse so steady and strong as in the former disease. The pulse is more excitable, irregular in strength and fre- quency, in the respective stages; more rapid and weak at the commencement, and partakes more of the asthenic character, in the latter malady; the emaciation is also greater and more rapid. — /.. The stools in encephalitis are devoid ofthe peculiar characters they present in acute hydro- cephalus; they are not of the same dark green- ish colour, have not the gelatinous consistence, with the oiliness and glossy appearance, of those in the latter; nor do they possess the peculiar sickly, but not fcetid smell.— i. The contrac- tions and spasms of particular limbs and muscles, often observed in encephalitis, are seldom met with in hydrocephalus; whilst, in the latter, para- lysis is more common. From the circumstance of inflammatory appearances in the membranes, as well as of softening in the central parts of the brain, having been often found in hydrocephalic cases, in addition to the effusion of fluid, it may be legitimately inferred, that the disease will often partake more or less of the symptoms usually caused by these lesions (see Brain, §§ 146—182. 214. et seq.); and that cases will occur but slightly modified in their characters from those consisting of inflammation on the one hand, and of softening on the other; the former commenc- ing suddenly and acutely, the latter slowly and insidiously. DROPSY, ACUTE, IN THE HEAD —Diagnosis. 667 246. (6) Acute hydrocephalus may be dis- ' tinguished from fever, by the somnolency, knit- ting of the brows, the great irritability of the stomach, which is increased by motion and the erect posture; by the raising of the hands to the I head, the throwing back the neck, the excitability and irregularity of the pulse, the peculiar char&c- I ter of the evacuations, and obstinate costiveness; by the pains shooting in various parts, and the overpowering headach which admits not of the head being raised, — the pain darting at intervals through the centre ofthe brain, and not throbbing | as in phlogosis, nor being increased or brought on by excited circulation; and by the starting, peculiar scream, and the expression of anguish when the child is awakened by it from the con- stant dozing, into which he instantly afterwards falls.—a. The infantile remittent fever is distin- guished from this disease by the absence of the above symptoms, by the expression, by the regular morning remissions, and by the feculent, brown, and more easily procured evacuations.—,-f. Ty- phoid or adynamic fever is rare in children, and is to be distinguished from this malady, by the more equable pulse, by the dark and fcetid stools and diarrhoea, low muttering delirium, supine posture, tumid abdomen, sometimes by .petechia?; by the dark brown, tough sordes on the teeth and gums; by the slipping down in bed; and by the absence of acute pains, convulsions, paralysis, and of the other remarkable symptoms of hydrocephalus. — v. The febrile disorders produced by worms are generally more protracted than this disease; are without distinct stages, but with manifest remis- sions,—the sleep being sound, and pulse uniformly quick. In worm fever, the pains in the head and abdomen are dull and not much complained of; the appetite is ravenous, the stools spontaneous and copious, the urine abundant and pale, the perspiration free, the cheeks generally pallid, the sight and hearing are unaltered, the mouth and nose moist, the abdomen is constantly tumid, and the body but little or not at all emaciated; and if convulsions occur, they are not followed by paralysis. It should not be overlooked, that either of these states of fever may give rise to aqueous effusion on the brain, the early symp- toms proceeding insidiously, or being masked by the primary disease, and thus often escaping de- tection until some of the characteristic symptoms of hydrocephalus supervene. 247. (c) Various organic lesions within the head may occasion very nearly the same series of morbid phenomena as constitute this disease; but generally they are of much longer duration, and are not attended by so much emaciation, or such overpowering pain in the head. The stages of the malady are not so well marked. Rarely, however, do organic changes occur in the ence- phalon or its membranes, in children, without the effusion of more or less fluid. 248. (d) The strangulating or crowing in- spiration, with purple complexion, not followed by cough (see Larynx — Spasm of), but often accompanied by clenching of the hand on the thumb, with spasms of the toes, has been con- sidered by many as connected with acute hydro- cephalus. Without denying that this affection may occur as a symptom at an early stage of the disease, it should be recollected that it often dis- appears after scarifying the gums, or cutting the teeth, or removing morbid secretions. The con- vulsions attendant on hydrocephalus are generally characterised, as Dr. Cheyne justly remarks, by a greater affection of one side of the body than of the other: one arm or leg is, with some reg- ularity, retracted and flung out, while the other is affected with spasmodic catchings; the eyes are suffused; there is often a circumscribed flush on the cheeks, and the breathing is slow, or irreg- ular and sobbing. 249. (e) Exhaustion of vital power may oc- casion symptoms often closely resembling acute hydrocephalus. The circumstance of exhaustion giving rise to hydrocephalic symptoms — in some cases without any effusion, in others with the collection of more or less fluid — has been well known to me, and acted upon in my practice at the Infirmary for Children for many years. It was first very imperfectly alluded to by Dr. Cheyne; and subsequently by Dr. Abercrom- bie, Dr. GoocH,Dr.Darwall,and others, who appear not to have clearly understood it. These writers consider this consecutive affection as one of exhaustion of nervous power only: but I in- fer that something approaching to hydrocepha- lic is occasionally connected with it; for the benefit afforded by nutrients, stimulants, or ton- ics, is no proof that the exhaustion has not been attended by some degree of effusion. Indeed, the physical condition of the brain renders it most probable that some fluid is collected, owing to exhaustion, diminished nutrition, and the state of the cerebral circulation; and that it is absorbed as the pathological states that occasioned its effu- sion are removed by appropriate treatment. The appearances observed in the fatal cases fully con- firm this view. I am at this time attending two cases of this affection that fully illustrate its nature. It is generally consequent upon wean- ing, improper or imperfect feeding, protracted diarrhcea, and exhausting treatment; and is usually attended by loss of flesh, increased sen- sibility and irritability, a feeble quick pulse, transient and irregular flushings, quick breath- ing, sometimes sighing or moaning, a white loaded tongue, scanty urine, and a mucous diarrhoea, — the evacuations being flatulent, unnatural, green- ish, or gelatinous. Sometimes there is increased heat of the head towards night, but seldom any pain or screaming. In addition to evidence of preexisting or attendant irritation of the digestive mucous surface, the bronchial lining, also, often indicates irritation by a dry hacking cough. This first, or irritative stage of the complaint is fol- lowed by one of more marked exhaustion, with stupor or torpor, particularly if the causes con- tinue in operation. The pupils become dilated; •the eyes vacant, and sunk in their sockets; the eyelids half shut; the countenance pale and cool; and the extremities, especially the lower, cold. If the complaint occurs during dentition, some- times squinting, with partial convulsions, or with crowingor croupy inspirations; slow, irregular, or suspirious breathing; clenching of the hands, or spasms of the fingers and toes; are observed. The feet and legs are always cold, and with difficulty kept warm, especially if the head be hot. The fontanelle is sometimes depressed, or nearly nat- ural. The pulse seldom or never loses its fre- quency. This torpid stage may terminate fatally with increased coma, a rattling respiration, sink- 668 DROPSY, ACUTE, IN THE HEAD —Prognosis —Causes. ing and disappearance of the pulse, and profound exhaustion. Convulsions occasionally occur, but at no particular period of the complaint. A fa- vourable issue frequently follows an appropriate treatment. In some of the cases which have ended fatally, I have found, on dissection, more or less fluid in the ventricles. The membranes were even less vascular than commonly observed in young subjects. In these cases, death is more to be imputed to disease in other viscera, and the attendant exhaustion, than to any change within the head. 250. (/) When acute hydrocephalus is con- secutive of scarlatina, measles, small-pox, &c, it becomes important to detect it as early as pos- sible. These diseases may terminate fatally, in their latter stages, copious effusion having taken place in the ventricles, and between the mem- branes of the brain; or the symptoms of this malady may not commence until a few days or even weeks after they have disappeared, more particularly after scarlatina. Severe and fre- quently recurring pain in the head at this pe- riod should always receive attention; and when this is attended with other symptoms of the first and second stages, decided measures should be adopted. When it follows scarlet fever, the occurrence of headach, stupor, or convulsions, either with or consequent on anasarca, may be viewed as evidence of approaching or commenc- ing effusion in the head, which may be averted by antiphlogistic and other appropriate reme- dies. 251. Prognosis.—This disease is not now so fatal as it was viewed by the first writers on it. If recognised early, a large proportion of cases will recover; even in the most advanced periods, the patient should not be despaired of. I have repeatedly seen recoveries take place, although strabismus, paralysis, convulsions, blindness, un- conscious evacuations, and other unfavourable symptoms, had existed some time. Data furnish- ed by the writings of Odier, Cheyne, Mills, Brichetf.au, Goelis, and others, show that from a sixth to a third ofthe cases has recovered. But a perusal of the cases they have adduced, has convinced me, that some of those which recover- ed, as well as of those that died, belonged to acute or sub-acute encephalitis — little or no effusion having taken place—several of them presenting, on dissection, this as the least important change; the fluid sometimes amounting only to two or three drachms,—a quantity not nearly sufficient to warrant the designation given to the disease. 252. Although the prognosis should always be given with much caution, and be generally un- favourable ; yet in few circumstances, indeed, ought the anticipation of such a result to paralyse our treatment. Dr. Cheyne justly observes that, whilst the pulse continues steady, and the breathing natural, the most .alarming symptoms should not prevent the use of active remedies. I would even go beyond this, and say, that the supervention of hurried breathing is the only symptom that should lead us to despair of the case. We should be cautious not to be misled by the falling in the frequency of the pulse in the second stage; and not to be induced to give a favourable prognosis from this circumstance. The coming down of the pulse should, therefore, be viewed in connection with the state of the eves, and ofthe evacuations, and with the other symp- toms, before any opinion should be formed from it. More copious and more readily procured bilious stools, and their more feculent appear- ance and natural smell, an increased flow of urine, mucous or watery discharges from the nose, and an abundant warm perspiration, are favourable signs. The occurrence of the disease in comparatively sound constitutions, in an in- flammatory farm, or after scarlatina, admits of greater hopes of recovery. This opinion is ac cordant with that of Goelis and Abercrombie, although it is different from that expressed by Dr. Cheyne. The idea of effusion in the head being necessarily fatal, has operated unfavourably in the treatment of the disease. I believe, from extensive and attentive observation, that, notwitli- standing the uncertainty of the existence of this change, it may be removed, when the powers of the constitution are not sunk too low. 253. When hydrocephalus follows protracted ill health, in scrofulous constitutions, in families where others have died of it, after remitting states of fever, during protracted convalescence, or when it steals on so as not to be recognised until it is far advanced, an unfavourable opinion ofthe result may be entertained. The breaking out of a vesicular eruption about the lips and face; total insensibility of the retina; great rapidity, small- ness, and feebleness of pulse; dryness ofthe mouth, lips, and nostrils; boring ofthe finger in the ears; hurried respiration, and partial sweats, particu- larly on the neck and back of the head; indi- cate approaching dissolution. Even when the treatment is followed by very striking amendment, we have no certainty of the recovery of the pa- tient; for most of the unfavourable symptoms have been removed; but, in one or two days, they have recurred, and death ensued. Even when an improvement has become more permanent, we cannot be sure of the result, until the actions of the iris return, and the alvine excretions, and other functions, become natural,—until then, a cautious opinion of the issue should be given. 254. Causes. — (a) The predisposing causes. — Goelis and several others suppose that the disease is more common now than formerly, ow- ing to the less frequency of eruptions on the heads of children. He also believes, and refers to facts in support of the opinion, that terror and anxiety in the mother during the last months of preg- nancy predispose to it,—the disease often appear- ing in the child soon after birth. The epochs of infancy and childhood are, however, the most remarkable predisposing causes. At these periods, the rapid developement of the encephalon, and the great susceptibility of the nervous system, dispose the cerebral circulation to frequent ex- citement; and in proportion as the cerebro-spinal system acquires a predominancy in capacity and function over other parts, is the predisposition to vascular determination, to inflammatory action, to increased exhalation of serum, and other disorders of the cerebral vessels, augmented. The more frequent occurrence of the disease, often in an inflammatory form, in children with precocious intellects and large heads, is a common observa- tion, and is confirmed by the experience of Gar- dien, Hopfengartner, Guersent, and others. The more usual period of attack is from the first to the eighth year; its frequency dimin- DROPSY, ACUTE, IN THE HEAD —Pathological Opinions. 669 ishing as we depart from this epoch, down to the period of birth on the one hand, and up to pu- berty and manhood on the other. I believe, that, previous to the tenth year, the disease is most frequent in boys. Dr. Cheyne thinks, with Ludwig, that, after ten, girls are more subject to it. A scrofulous diathesis is also one of the most remarkable predisposing causes,—sometimes sev- eral children being carried off in a family where it exists. Cheyne, Spr eng el, and others, con- sider that hydrocephalus and scrofula are conver- tible into each other. That the former sometimes follows the disappearance of other scrofulous af- fection, admits not of doubt; but it rarely happens that the latter is influential in the removal of the former; indeed, effusion on the brain much more frequently proceeds simultaneously with tubercu- lar and other strumous diseases in other parts of the body. 255. Hereditary disposition has also been view- ed as a cause by Quin, Odier, Formey, P. Frank, Portenschlag, Baader, Goelis, &c.; some, however, with Cheyne, imputing such disposition to the scrofulous diathesis. But I have repeatedly remarked the hereditary tenden- cy, without its dependence ou scrofula. Goelis, Bracket, Coindet, and Girtanser ascribe this disposition to a peculiar connate irritability of the nervous system; this, however, does not ad- vance the question much further. The children of parents addicted to drunkenness, particularly if the mother be given to the use of spirituous liquors during suckling, are also, according to my experience, prone to be attacked. In addition to these, may be enumerated a syphilitic taint of the parents (Thom); frequent congestions in the head, however induced; the use of too stimu- lating food and drink in early age; keeping the head too warm; the premature and excessive exercise of the senses and of the intellects; vio- lent mental emotions, as terror, anxiety, anger, fear; the exhibition of anodynes to the child by nurses, or in the treatment of other diseases; re- peated falls; injuries during parturition (Stoll, Arantius, Goelis); rocking in cradles (Blan- card, Anat. Prat. c. i. obs. 18.); the early and repeated application of cold to the head or other parts (Percival); concussions of the body; too frequent motion and depending positions of the head; whirling round on the toes; the injudi- cious use of emetics; the continued irritation of worms in the prima via, and of dentition during both the second and first periods; congestions, inflammations, and enlargements ofthe liver and spleen; previous attacks of encephalitis, or of cerebral congestion; interruptions to the secre- tion and discharge of the bile; disorders of the stomach and bowels; enlargement and obstruc- tion of the mesenteric glands; long continued costiveness; remittent and exanthematous fevers; pertussis; previous diseases imperfectly cured; and affections much disordering the respiratory functions. Dr. Thompson, of Jamaica, observ- ed it frequently consequent on worms in the dark races. 256. (6) The exciting causes are, cold to the head of young infants; external injuries from falls, blows, &c; concussions or agitations ofthe brain, from jumping, whirling, or depending po- sitions of the head; the suppression of eruptions on the scalp, and behind the ears (Conradi, Goe- | lis, &c); the extension of inflammation from the ear (Itard, Lallemand, &c.); the retroces- sion of acute eruptions, and suppression of chronic evacuations or discharges; the extension of irri- tation to the membranes or brain, from inflam- mations of the organs of sense, from the throat, scalp, face, &c, and from erysipelas of those parts; too copious general depletions in the ex- anthemata and acute diseases, in relation to the form of the malady and strength of the patient; the too liberal use of narcotics in young children, or their employment too early in several diseases, particularly in hooping cough, spasmodic croup, spasm of the larynx, and flatulent colic; whirl- ing, tossing, or rudely rocking children in order to quiet them, when crying from disorders of the digestive organs, or erethysm or irritation of the encephalon; insolation; the early use of fer- mented liquors ; carrying heavy loads on the head (J. Johnson); allowing children to sit on stones or other cold seats; and the metastasis of various maladies. Rush, Lettsom, Goelis, and Coindet mention its occurrence from metas- tasis of rheumatism. I have seen this take place in a grown-up person,—the effusion being chiefly between the membranes, — but not in children; although I have met with metastasis to the heart in many cases of children — in one case now un- der treatment, which is the second in the same family. (See also Brain, §§ 182, 183.) 257. Pathological Opinions.—Acute hy- drocephalus has been generally classed as a drop- sical disease, although its claims to be thus arranged are somewhat equivocal. Its similarity, however, to other acute dropsies, particularly those of the chest, is most striking. Indeed, it seems to hold such a relation to inflammation on the one hand, and to chronic dropsy on the other, as to entitle it to be viewed as an intermediate disease, and as identical in most cases with other acute dropsies; in some instances approximating more nearly to the one than to the other. Whytt considered it as altogether a dropsical malady; and Dr. Cul- len, in designating it apoplexia hydrocephalica, did not seem to entertain a very different opinion. Pin el fell into the same views, after having de- scribed it as a species of cerebral fever; which was the idea conceived of it by Dr. Macbride. Con- temporary with, and subsequent to, the appearance of Dr. Q,uin's work, numerous authors, particu- larly Rush, Rand,Withering, White, Ack- ERMANN, GARNETT, MARTINI, HeINECKEN, Gardien, Goelis, and Raimann, treated it as inflammatory in its origin; and a number of French pathologists, especially Martinet and Parent- Duc hate let, have viewed it as arachnitis of the ventricles and base of the brain. Others, again, have supposed, with Lallemand and Aber- crombie, from the frequency of disorganisation of the cerebral structure in the vicinity of the ven- tricles, that it is a consequence of inflammatory softening or cerebritis; the disease either com- mencing in, or extending to, the arachnoid of the ventricles. Rostan (Clin. Med. t. ii. p. 321.) has stated it to be a result of inflammation or other lesions of the brain and membranes, and seldom or never an essential disease. This is doubtless the case, if we consider all sensible le- sions as sequences of anterior changes; but when the nature of the early changes cannot be readily inferred from the alterations they induce, we must 61 670 DROPSY, ACUTE, IN THE HEAD —Pathological Opinions. be contented to grapple with the obvious malady, until we know more of its antecedent pathological states. If we adopt the views of M. Rostan, no changes, excepting those immediately consequent upon remote causes, will be considered essential. 258. Several writers, observing the history and lesions of hydrocephalus to differ in several respects from inflammation, yet still to resemble it very closely, have viewed it as a peculiar form of in- flammatory action affecting the more interior sur- faces and substance ofthe brain. Thus, Conra- di termed it Encephalitis exudatoria infantilis; Brachet, Hydrocephalite, or watery inflamma- tion of the brain; and Coindet, Cephalite interne hydreneephalite. ■ Other writers, particularly Ab- ernethy, Curry, Cheyne, Yeats, Thom- son, &c, have considered it as most commonly proceeding from disease in the digestive organs, and seldom arising from primary inflammatory ac- tion in the brain or its membranes. This opinion has been carried too far; for I have often had evi- dence to convince me, that morbid action had been proceeding in the brain long before it was suspect- ed, and that one of its chief effects was to disorder the liver and digestive canal; this sympathetic dis- order being frequently considered as primary, and its reaction on the brain as the sympathetic pro- duction of hydrocephalus. I believe that the mal- ady often originates in the substance ofthe brain; and that, conformably with what is observed in respect of lesions of this structure, the digestive viscera, frequently at one time the most remarka- bly deranged, are merely sympathetically affected. Formey and Dr. Shearman have viewed the effusion as a consequence of simple excitement of the cerebral circulation, entirely independent of inflammation. The latter writer has consider- ed it to be contingent on various diseases, and to arise from a diversity of causes; but that its oc- currence is chiefly owing to the predisposition or previous state of the membranes, — the essential character of the disease consisting in that previous state or predisposition which, in connection with an excited state of the circulation, gives rise to increased exhalation or effusion. Dr. C. Smyth has argued against inflammation, and in favour of debility, as the cause of the effusion; but whilst he has strenuously contended for the latter patho- logical condition as respects the tone ofthe extreme vessels, he has admitted the existence of accele- rated circulation, and its influence in producing the disease. There is one inference, however, in which nearly all modern pathologists agree, viz., that the effusion itself does not constitute the malady, but is only its consequence, — contrib- uting to the production of the more advanced symptoms, but in a less degree than many sup- pose. 259. Pathological Inferences.—(a) The first or nervous form of acute hydrocephalus is frequent- ly consequent upon changes in the substance of the brain, in the membranes lining the ventricles, and in the vessels and circulation of the encepha- lon, probably arising from the state ofthe organic nervous influence supplied to this quarter, and to the perversion ofthe vital actions. (See Disease, § 87—92.)—(b) That these changes often com- mence gradually, or almost imperceptibly, and proceed far before they disorder the functions, either of organic or of animal life, in a remarkable degree; and when such disorder becomes manifest, it is often difficult to trace the quarter in which it has originated, owing to the intimate dependence of both classes of functions upon the organic ner- vous system. — (c) That the changes observed on dissection in this variety have evidently been in progress a considerable time before effusion has taken place; the effusion being the consequence of these changes, assisted by the physical condi- tion of the encephalon. — (d) That nervous, as well as inflammatory and consecutive, hydroce- phalus being merely contingent upon lesions of the organic nervous influence, of the circulation, and of the substance and membranes of the brain, such lesions actually constitute the disease during its early periods. — (e) That the nature of the cerebral affection, and the exact state of vascular action, in these periods, are not manifest: but if it be at all inflammatory — which admits of dis- pute — the vascular action possesses more of an asthenic or ataxic, than of a sthenic, character; or is attended by a perverted, rather than by a dynamic, state of vital power; and by imperfect performance of the digestive and assimilating functions.—(/) That, although the first form of the disease be consecutive of changes in the cir- culation, or in the organic nervous influence of the brain, the resulting phenomena may be such as to be mistaken for the exciting causes; the organs of locomotion • may be so enfeebled as to occasion falls, which will aggravate the primary affection, and develope a state of sub-inflamma- tion, or of vascular reaction in the encephalon, and its usual consequences, viz. determination of blood, injection of vessels, and effusion of serous fluid; or the viscera of digestion and sanguifac- tion may become so congested, or otherwise dis- ordered, as to appear the parts primarily affected. — (g-) That when this form is coincident with, or consecutive of, congestion, inflammation, or other disorders of the digestive and chylopoietic visce- ra, effusion into the ventricles cannot be viewed as the earliest changes that take place within the head; but that this effusion is merely conse- quent upon similar changes to those which have been already alluded to (d, e); the lesions in the digestive organs, as well as the earlier alterations in the brain, being, very probably, coetaneous results of pre-existing disorder of the system, or of constitutional vice.— (h) In whatever quarter disorder commences, it is probable that, some- times at least, the sensorial power becomes ex- hausted, possibly coetaneously with the super- vention of the second stage, and the cerebral tissue itself more or less wasted; but it is difficult to say whether this wasting be the consequence, or the cause, ofthe effusion into the ventricles,— possibly the latter.—(i) That, in the early stage of the disease, as well as in its progress, the vas- cular excitement, or febrile disturbance, attending it, is characterised by general adynamia or per- version of vital power.—(k) That great cerebral excitement does not necessarily imply the exist- ence of inflammatory action iu the encephalon; for accelerated circulation in a weakened state of the frame, and susceptible condition of the senso- rium and nervous system generally, will produce cerebral excitement, particularly towards the close of febrile or protracted diseases; but this, instead of being inflammation, is a state very different from, or sometimes even opposed to, it, as shown by the ladentia and juvantia, and by DROPSY, ACUTE, IN THE HEAD —Treatment. 671 the post mortem appearances.—(I) Tn the second form, and in many of the .third, particularly as occurring after the exanthemata, the symptoms, as well as the appearances after death, are more man- ifestly inflammatory; cases varying in grade from such as are described in the article Brain (§174.), until the characters of the nervous form of the disease are nearly approached; the inflammation differing in kind accordingly from sthenic inflam- mation, owing to the diathesis and the state of vital power.—(m) That the waterstroke or hy- peracute disease, in every case in which I have observed it, has arisen independently of inflam- mation, although generally consequently upon determination to, or congestion in, the head.— (n) That hydrocephalus, particularly its nervous form, may assume intermediate states or grades between the acute and chronic, which grades may be denominated sub-acute.—(o) That the disease may, in some instances, commence in an acute or sub-acute form, and become chronic, especially in infants whose cranial sutures have not closed. — (p) In some cases, also, the acute or sub- acute may supervene on the chronic state. — (q) That acute dropsy in the ventricles, although most common previously to puberty, may occur at any subsequent period, especially during the decline of life, and iu old age.—(r) That it is, in such circumstances, generally attended by in- flammatory appearances in, or softening adjoin- ing, the surface of the ventricles; but it some- times is unattended by any of these lesions.—(s) That in these cases it often terminates fatally in a short time, with apoplectic or comatose symp- toms; constituting the Serous Apoplexy of authors, which is sometimes consequent upon other forms of dropsy in persons advanced.in life; they being cut off by the effusion into the ventricles, with- out any other material change within the head,— the coma, or apoplexy, gradually becoming more and more complete until life is extinguished.* 260. Treatment.—Lit.Hist. of.—The opin- ion of Dr. Whytt, as to the nature of acute hy- drocephalus, and which was for a time very gener- ally adopted, led to an inefficient treatment. Dr. Watson, who adduced one of the first successful cases, trusted chiefly to blisters, purgatives, means to lower the attendant fever, and to the powers of the constitution for a cure. Drs. Haygarth and Dobson were the first to prescribe mercury in the disease, particularly calomel, — a medicine which had been very largely employed about a century before, but had fallen into disuse; and which, having proved extremely efficacious in many of the maladies, incidental to Europeans in the East Indies, was then finding its way, through means chiefly of Dr. Lysons, Dr. Hamilton, and Dr. Clark e , into the practice of this country. Dr. Dobson exhibited mercury with the intention of thereby increasing the function of absorption; and Dr. Haygarth, in order to induce saliva- tion, with the expectation that, by procuring an aqueous evacuation from the neighbourhood, it * Since the above was sent to press, the fifth volume of M. Andral's '-Clinique Midicale" has appeared. It con- tains a few cases of idiopathic and acute effusion of fluid into the ventricles, occurring in adults, both without and with slight inflammatory changes or softenings of the surfaces of these cavities, or parts adjoining. The symptoms, in these cases, were those of waterstroke, or of serous apoplexy. Two cases occurred in persons who were labouring under dropsy of other cavities. might be the means of removing the fluid accu- mulated in the ventricles. Drs. A. Dawson, Sim- mons, and White placed their chief reliance on blisters and opium,—means which, in the present state of our knowledge, amount merely to useful adjuvants. The views of Drs. Q,uin, Withe r- | ing, and Rush caused a revolution in the treat- ment of acute hydrocephalus. Dr. Q,uin, ob- serving in dissection, evidences of inflammatory action in the membranes of the brain, advised bloodletting, and cold applications to the head, in the first stage, and mercury afterwards; Dr. Withering used digitalis, but his cases were not sufficiently demonstrative of its efficacy; and Dr. Rush placed confidence chiefly in large bloodlettings and active purgation. 261. Dr. Percival was amongst the first who appears to have been aware of the fact, that, however nearly acute hydrocephalus may ap- proach true inflammation, it is no more identical with it, than the adhesive form of inflammation is the same as the diffused, or as erysipelas. He directed the means which had been previously recommended, according to the circumstances of the case; and combined the use of blisters, mer- curials, and opiates, with that of squills, musk, and other diuretic and nervine medicines. Con- sistently with these views, he was cautious in the employment of bloodletting. Dr. Paterson prescribed calomel and opium, and a more anti- phlogistic treatment than was risked by Dr. Pe r- cival; but Dr. Garnett, although he believed in the inflammatory nature of the complaint, hardly ventured beyond local depletions; and confided more in digitalis conjoined with mercu | rials, than in other internal remedies. 262. It is impossible for the experienced read- er to have perused the writings on the disease, as far as I have now proceeded, without being for- cibly struck with the circumstance, that great misapprehension prevailed as to the succession and ensemble of morbid phenomena, on which the name acute hydrocephalus has been imposed. This is shown by many of the cases adduced by authors in support ofthe inflammatory nature of the disease; these cases exhibiting the usual re- sults of inflammation only: whilst those who observed the fluid collection unattended by very remarkable inflammatory appearances, limited their idea of this malady to such as these only, and considered them as distinct from those evinc- ing changes strictly referrible to inflammation, without any, or with but little effusion; which latter cases they viewed as constituting true in- flammation of the brain and its membranes, and not falling within their definition of hydrocepha- lus, however nearly the symptoms of the one resembled (in consequence of the physical con- dition of the brain) those of the other. The fact is, that the larger number of writers down to the present day applied the term acute hydro- cephalus to a certain succession of phenomena, without regard to the different pathological states giving rise to it, and the shades of diver- sity by which each may be recognised; and were either unaware of, or unheeded, the circum- stance, that an inflammatory state of the brain and its membranes in young subjects may termi- nate without effusion, or may give rise to effusion to an extent warranting the denomination of hydrocephalus; and that, moreover, water may 672 DROPSY, ACUTE, IN THE HEAD —Treatmeht. be collected within the cranium, without any truly or sthenically inflammatory action of the vessels; and, nevertheless, the most experienced observers often will hardly be able to distinguish, by means of the symptoms, between these classes of cases. 263. The intentions with which the treatment of acute hydrocephalus should be conducted, are resolvable into the following : — 1st. To remove all causes of irritation or morbid action oper- ating either directly or sympathetically on the brain. — 2d. To lower vascular excitement in the head, and equalise the circulation. — 3d. To guard against effusion, by fulfilling the above ob- jects, by diverting the morbid determination of fluids from the head, and by changing the action of the extreme vessels.---lth. To restore dis- charges and eruptions, when these have been sup- pressed.— 5th. To alleviate pain and sickness. — And, 6th. To support the powers of life, and to recruit them when they are sinking. It is obvious that the means which will accomplish one of these intentions, will often also fulfil one or more of the others. 264. The physician, having considered the origin, pathological states, the constitutional rela- tions, the form, history, and stage of the disease, as well as the means which may have been al- ready employed, should cause the patient to be placed in a well-aired chamber, and to be screen- ed from strong light. The bed or couch should approach a slightly inclined plane, from which he ought to be slowly raised, and on which gently placed, when removal is necessary. All quick motions or changes of position, as well as excitement of the senses, and irritation of the temper, must be carefully avoided. The tem- perature should be rather cool than warm, and the bedclothes only sufficient to preserve the natural heat. With these preliminaries, the re- medies determined upon should be promptly and faithfully administered. During both the first and second epochs of dentition, the patient's gums and teeth ought to be carefully examined, and the former freely incised, or the latter removed, as often as may be requisite. 265. A. Vascular Depletion. — In estimating the reported success of treatment in this disease, it is very necessary to keep in recollection that often no distinction has been made between it and encephalitis : indeed, many modern writers consider inflammation of the brain and its mem- branes, occurring in children, to be identical with acute hydrocephalus,—or, in other words, that this latter is the same as the phrenitis of adults. Now this sophism, so general and injurious in medicine — this affirming as true of the genus, what is true merely of the species — has had a most baneful influence on the treatment of this disease, inasmuch as it has led practitioners greatly to over-estimate the advantages of sanguineous depletions; a large proportion of their cases of imputed acute hydrocephalus being acute and sthenic meningitis or encephalitis, in which this evacuation may be carried much further than in the former malady; and has induced them to re- commend, and others to employ, the practice with too little reservation. This circumstance is espe- cially manifest upon perusal of the histories and treatment delineated by Rush, Maxwell, and several others, who have carried bloodletting as far as it is admissible in sthenic inflammation of the membranes. Having perused these author- ities, after the experience derived from the treat- ment of very many hundred cases of cerebral diseases in children, I am convinced that the larger proportion of those which they considered hydrocephalus, was neither that malady, nor would have given rise to effusion in such quantity as to have justified the designation : the details they have furnished are decisive of the fact in the mind of the competent judge. Therefore, let not the inexperienced practitioner be led astray by the circumstance of its having been recorded by au- thors, that arteriotomy, large bloodlettings, &c, cured half the cases in their practice; I am con- vinced that the majority of such cases were simple encephalitis, or inflammation of the membranes of the base of the encephalon. Dr. Maxwell avers that he cured sixty cases out of ninety — two thirds — by bleeding them in the horizontal posture until insensibility — occasionally for some hours — afterwards ensued. Would the most heroic practitioner of the present day attempt such practice in an undoubted case of acute hydrocephalus ? I believe not. 266. (a) In the more inflammatory states of the disease, and especially in the first stage (§ 234.), the same means, as are fully described in the treatment of inflammations of the Brain and its membranes (§ 191. et seq.), should be employed; aud to an extent which the pulse, the febrile excitement, and previous health and strength of the patient, will point out. These means consist of general or local bleeding, active purging, the application of cold to the head, de- rivatives and counter-irritants, mercury, sedatives, and diuretics, &c. In the inflammatory form, as it occurs either primarily or consecutively, these remedies may be prescribed very nearly in the manner explained in the article referred to. When the disease supervenes suddenly on any of the exanthemata, as decided depletory mea- sures, as are advised for encephalitis thus occur- ring, must be pursued. (See Brain, § 191.) In children under three or four years of age, leeches, or cupping behind the ears, on the occi- put, or on the nape of the neck, will be prefera- ble to venaesection ; but, after this age, the latter method may be practised in the first stage of the disease. I have observed no greater advantages obtained by bleeding from the jugular, than by bleeding from the arm. Many Continental physi- cians consider depletion more derivative when it is practised in the feet, and numerous facts favour the inference. In the second stage, local deple- tions, if they have not been already employed, or carried sufficiently far, and if circumstances indi- cating the propriety of the practice exist, may still be resorted to; but with strict reference to the pulsation of the carotids, the pain and tem- perature of the head, to the warmth of the ex- tremities, and to the state of vital power. I have often derived advantage from repeated local bleed- ings even in this stage, aided by the other reme- dies enumerated, when employed in the manner about to be described. 267. (b) In the first form, as well as in such of the third as partake chiefly of the same char- acter, vascular depletion must be employed with greater caution, and as early as possible in the first stage. I have seen hardly any benefit from it v\ hen the second period of this variety had com DROPSY, ACUTE, IN Tfl menced. When the disease has been detected sufficiently early, and when it has followed pre- vious attacks of congestion or inflammatory action in the head, the febrile excitement being neither general, continued, nor well marked, the applica- tion of blisters behind the ears, and of leeches around, or close to, the blisters, has been of much service. But it will be requisite to repeat this practice every second or third day, or oftener, and to carry it as far as the circumstances of the case may warrant. If the cerebral affection appear to have been induced by disease of the digestive and chylopoietic viscera, a blister should be placed on the epigastrium or right hypochon- drium, and leeches applied around it, as soon as redness is caused by it; when it ought to be re- moved. This method may be repeated, according to circumstances, after intervals of one, two, or three days : it possesses great advantages in this state of the disease, inasmuch as, whilst it relieves the gastric symptoms and the affection of the liver, it is a most energetic derivative from the head, without reducing vital power so far as gen- eral depletion does; for general bleeding, how- ever early employed in this variety, is seldom productive of much benefit. Indeed, I have seen it detrimental in many instances; and I consider both it, and local depletion, if carried to any considerable extent, as decidedly injurious in some states of this form, particularly in weak and cachectic children. 268. B. Cathartics.—The discharge of morbid secretions and faecal collections should be pro- cured as early as possible by remedies calculated, at the same time, to derive from the brain, and to diminish vascular plethora and excitement. The fulfilment of this intention is appropriate to all the states of the disease. A large dose of calomel, either alone or with James's powder, ought to be immediately exhibited, and, after three hours, repeated with the addition of toasted jalap, or scammony; and its operation should be promoted by an active terebinthinate enema. If the irritability of stomach be such as to prevent the retention of medicine taken by the mouth, vascular depletion, a blister or mustard cataplasm on the epigastrium, and an active cathartic ene- ma, will often remove it. Calomel, in full doses, will generally be retained, under any circumstan- ces; but, in conjunction with cathartics, it is fre- quently ejected, unless after the measures now stated. Elaterium, in small and repeated doses, has been suggested by Dr. Elliotson; but it, as well as croton oil, will seldom be kept on the stomach. When retained, they are occasionally of use. I have seen most advantage derived from the latter, when it has been added to the terebinthinate enema, or applied over the abdo- men as a rubefacient. Dr. Cheyne found a drachm or two of magnesia saturated with lemon juice, given every two or three hours, most use- ful in such circumstances; and I believe that this will act more certainly than irritating purgatives, particularly if a full dose of calomel have been taken a few hours previously. A gruel or broth enema containing some purgative salt may also be administered two or three times in the course of the day; and if the bowels be very torpid, and the sopor considerable, the terebinthinate enema should be repeated daily, or even oftener. Saline purgatives may also be given in the infusion of IE HEAD —Treatment. 673 senna, when they can be retained. Active ca- tharsis at the commencement of the disease, after vascular depletion has been instituted to an extent which the nature of the case demands, will have a more decided effect than any other means whatever. 269. C. Cold applications to the head, the hair having been removed from it, should be em- ployed in the manner, and with the precautions, directed in the article Brain, § 192., whenever the temperature of the head will admit of them. But, like the measures already advised, it is only early in the disease, and in the inflammatory states more especially, that they are productive of much benefit. In these states they may be used simul- taneously with the tepid semicupium or pediluvia, salt and mustard having been added to the water. Rush, Q,uin, Conradi, Formey, Goelis, and nearly all the writers on the disease, are fa- vourable to cold applications in its treatment; and, in some form or other, they are appropriate to most of its states. 270. D. Mercurials.—These are, perhaps, the next important means that can be employed. They have been very generally prescribed since they were first adopted by Dobson and Hay- garth, and subsequently by Eason, Mackie, Reeve, Lettsom, Hooper, Hopfengart- ner, Ferriar, and more recent writers. Early in the first stage of the disease, calomel, given every three or four hours, in full doses, either alone or with James's powder, in small quantities, is, in ordinary circumstances, the best preparation. In children under one or two years, neither sali- vation, nor much intestinal disorder, will be pro- duced by it. In those above three or four years, its specific action may be obtained, but with little certainty, even although it be conjoined with opium or the compound ipecacuanha powder. When no essential benefit has accrued from the foregoing means, and the bowels have been fully purged as directed above (§ 268.), then calomel may be given with digitalis and narcotics, or with the latter only, particularly opium or hyoscya- mus, with the view of fulfilling the third and fifth intentions of cure (§ 263.). But in young children, especially when the bowels are griped or are irritable, the hydrarg. cum creta, with small doses of compound ipecacuanha powder (F. 653.), will be most serviceable. The bowels, however, should always be kept sufficiently free by either ofthe enemata recommended (§ 268.). I may add, that calomel has been prescribed with cantharides, by Dobson; with James's powder, by Campbell; with opium, by Leib and others; with digitalis, after local depletions, by Weaver, Goelis, and Fischer; with digitalis and arnica, by J. P. Frank; and with active purgatives (in which form I believe that it is most generally be- neficial), by Hufeland,Cheyne,Abercrom- bie, and many others. Dr. Merriman and my- self have given very small doses of the oxymu- riate of mercury, every four or five hours, with advantage. In the second stage, this is one ofthe best preparations that can be prescribed; but it requires much caution; and, in this period of the first and third forms of the disease, it should be prescribed in tonic and diuretic infusions. The utmost care should be taken in exhibiting mercu- rials in these forms, particularly in cachectic subjects, and where the powers of life are much 674 DROPSY, ACUTE, LN THE HEAD—Treatment. reduced. The state of the gums, mouth, and tongue, should be always carefully observed dur- ing their use; fori have seen fatal sloughing of these parts follow from them in such cases. The external employment of mercurials has also been recommended by Campbell and others. The ointment may be rubbed into the scalp, or between the shoulders, in the more urgent cases; but I have seldom seen advantage derived from this method. Mercurial ointment may also be em- ployed in dressing blistered surfaces; or the lini- ment may be applied to them on warm bread and water poultices. This plan has sometimes been productive of benefit, particularly in children of two or three years of age or upwards. 271. E. Derivatives and Counter-irritants are often serviceable, especially in the second stage. They are also admissible in the first stage of the first and third forms, when there is little febrile heat, or when the lower extremities are cold or cool. Blisters have been very generally preferred by Mondschien, Rush, Odier, Percival, Cheyne, Hopfengartner, Goelis, &c.— Much difference of opinion, however, exists as to the places to which they should be applied. They may be placed between the shoulders, on the thighs or legs, on the epigastrium, and on the neck and occiput, and behind the ears, in the earlier stages of the disease; and in infants they should be re- moved as soon as they produce redness. In the first stage, they ought to be preceded or ac- companied by depletions (§ 266, 267.); and in older children they may be kept discharging for several days, or be repeated. Some writers, and especially Portenschlag, White, Hop- fengartner, Simmonds, Gardien, and El- liotson, have advised them to be placed upon the head or occiput ; but I have never seen benefit derived from them in the former of these situations, unless in cases where the disease has followed the suppression of tinea capitis, or in the second or third stages, when the sopor has been great; and then the blister may be large, and the part over the occiput kept discharging for some time subsequently. In infants, sina- pisms to the epigastrium, or lower extremities, are often preferable to blisters in these situations. The tepid or warm semicupium and pediluvia, salt and mustard having been put into the water, are often of use in the second stage, or in the first, when the extremities are cool; but when there are general febrile excitement, and much heat in the head, they are seldom of service, unless in a tepid state, and in conjunction with cold applications to the head after evacuations have been directed. The warm bath is less ser- viceable than the semicupium, and is as often detrimental as beneficial in the early periods of the more inflammatory states of the disease. The vapour bath has been proposed by Dr. A. Hunt- er. -M. Itard advises it to be impregnated with vinegar. This practice is admissible chiefly in the second stage. Setons and issues are too slow in their effects for this disease; and the same may be said of the tartarised antimonial ointment. But I have seen benefit result from producing erubescenc-e by croton oil. In the latter stages, urtication may be practised. Moxas have been applied to the occiput and behind the ears, by M. Regnault. Dr. Merriman has had re- course, in several instances, to the tinctura lyttce in doses of from five to ten minims, given every four hours, until severe strangury was caused by it; and in three of these cases the disease was ar- rested. It may act beneficially, not merely as a de- rivative, but is an excitant of nervous power. 272. F. Sedatives and Narcotics.—(a) Digi- talis has been much employed in this disease since it was first recommended by Withering. Brown, White, Cheyne, and others, have mentioned it favourably. Any of its preparations may be used. Gardien prefers the setherial tincture, which he directs both internally, and ex- ternally in liniments. Goelis and Merri.iian prescribe half a grain of the powder with a grain of calomel every four or six hours; and Wknd- elstatt, any of its formulae with opium. Kle- ber advises that it should be rubbed in over the scalp, with the vinum sdlla. It may be given in both the first and second stages;—in the former as a sedative of vascular excitement; in the latter, to modify the state ofthe capillary circulation, and prevent effusion. Much discrimination, however, is necessary in distinguishing the effects of this medicine from the symptoms of the second stage —particularly the vomiting, slowness of the pulse, and dimness of sight. Dr. Cheyne points out certain differences between them; but they can- not be relied on. The sopor and strabismus, however, of this stage will generally distinguish it from the depression produced by digitalis. When this substance is prescribed in the first stage, it should be given at once in a full dose, and be repeated every four or five hours. In the second stage it may be conjoined with squills, the spiritus aetheris nitrici, or with serpentaria, or the decoction of the flowers of arnica, as advised by several German physicians. Colchicum has also been employed in this disease, within the last few years, with the same intentions as digitalis. I am unable to speak of its effects, as I have considered it less appropriate than this and some other remedies. It may, however, be prescrib- ed in the same stages as digitalis. Little benefit can be hoped from it, especially in the sec- ond period, unless it act upon the kidneys or bowels. 273. (b) Opium.— Percival, Odier, Crampton, Brooke, and many of the writers already referred to, recommend this substance in the second and third stages, particularly when the pain in the head, the convulsions, and irritability of the stomach and bowels, are very prominent symptoms. In the earlier part of the second stage it may be given with calomel, James'6 pow- der, or antimony. When the bowels are very irritable, without sickness at stomach", it is prefer- able in the form of Dover's powder, with hy- drarg. cum creta; and, when the general irritabil- ity is great, or the convulsions violent or frequent, with full doses of digitalis. Later in the disease, I have seen benefit from it in small doses given in the terebinthinate enema directed above, or with serpentaria, or diuretics. Hyoscyamus may be employed with the same intentions, and in similar states of combination, as opium; but I doubt its being equally efficacious. 274. G. Anlimonials. — The tartarised anti- mony, in large doses, — in from five to twenty grains in the twenty-four hours,—has been advis- ed by the followers of the new Italian doctrine, and employed successfully by M. Laennec in a DROPSY, ACUTE, IN THE HEAD— Treatment. 675 few instances. Although long in the habit of having recourse to this practice in pulmonary and some other diseases, I have had no experience of it in acute hydrocephalus. Small doses of James's powder with calomel, or with calomel and active cathartics, or with calomel and opium, as pre- scribed by Dr. Cheyne, appear the most judi- cious mode of directing this mineral. I have seen, however, benefit follow moderate doses of the tartarised antimony, either with or without opium, as recommended by Dr. Mills, in the first stage of the disease, when vascular action and febrile excitement were great. 275. H. Diuretics, fyc. can be but little con- fided in; yet I have believed them to have been of much service in the second and third stages of some cases. The most energetic is certainly the spiritus terebinthinae, in the form of enema, or of liniment rubbed on the scalp. Squills, digitalis, spiritus aetheris nitrici, spiritus juniperi, or hydro- chloric aether, — formerly Clutton's febrifuge spirit,—may be used, in these periods, with small doses of opium, or with a weak infusion of ser- pentaria, or decoction of the flowers of arnica. Flajani and Kleber prefer squills to other diuretics; and I believe that they are not altogeth- er without efficacy. 276. J. Paliatives and Restoratives. — The pain in the head and vomiting are to be relieved by the local depletions, — behind the ears and from the epigastrium,—and blisters in these situ- ations; by the cold affusion on the head; by calomel with opium, and by the terebinthinate enema; or a warm terebinthinate epithem or sinapism placed over the stomach, till redness is produced. Convulsions, in the earlier periods, will be abridged by the cold affusion, and most certainly by the enema just recommended. A tobacco enema ought not to be hazarded. The oxide of zinc, or musk with ammonia, or with small doses, of opium, may also be employed to relieve this symptom in the latter stages. I be- lieve that practitioners in this country * have been too often deterred from the use of restoratives in the advanced periods, particularly of the nervous form, of the disease. I have, in several instances, seen benefit follow the cautious exhibition of them along with diuretics, and enemata with assa- fcetida. The preparations of ammonia with tinc- ture of squills; or camphor mixture with magne- sia, the tincture of valerian, and syrup of roses; or the weak infusions of arnica or of serpentaria, with liquor ammonias acetatis, digitalis and syrup of squills; or a weak infusion of green tea, either alone or with digitalis, and spiritus aetheris nitrici; and either of these, with a drop or two of lauda- num, in small doses at short intervals, are the medicines I have most frequently had recourse to in the latter stages; allowing the patient beef tea, * The following Is an abstract, made in mv note book manv years since, of the practice of the most able German physi- cians in thU disease. In the nervous or typhoid variety, cold applications to the head, sinapisms to the arms and legs, and purgative clysters. If these fail, digitalis, with the decoction of (lores arnica; or infusion of serpentaria; blisters from the occiput to between the shoulders Io be kept open, the inunc- tion of mercury three or four times a d ly ; and, if the vomit- ing persist, sinapism* on the epigastrium. Subsequently musk and ammonia, chiefly on account of the convulsions. In the inflammatory form, and in that consequent on the exanthemata, local bleedings, digitalis, calomel and jalap, and, in the latter stages of these forms, the treatment direct- ed for the nervous or typhoid variety. warm jellies, &c in addition. In several cases approaching the sub-acute form of the disease, I have prescribed a solution of the hydriodate of potash in distilled water, with or without a little iodine added to the solution, in small but frequent doses, and with evident advantage. In a few cases, the compound infusion of roses, or a weak infusion of cinchona, or of valerian, have been given with some aromatic water, and with squills or spirits of nitric aether. 277. Treatment of the hyper-acute Hydrocephalus.—But little can be done in this form of disease, owing to the circumstances under which it usually occurs, and to its severity as well as rapidity. In cases consequent upon ex- haustion, the sopor or coma being profound, a blister on the head, the terebinthinate enema, and the treatment advised for the advanced stages of the acute hydrocephalus, are most likely to be useful. When it appears with less evident signs of exhaustion, leeches to the occiput or behind the ears, or cupping between the shoulders; ac- tive derivatives; a cold terebinthinate epithem applied around the head, and a blister on the epigastrium, with such internal medicines as the circumstances of the case require, conformably with what has been above stated; seem to be the most active and appropriate measures. The bowels should be energetically acted on, by me- dicines given by the mouth and exhibited in enemata, whenever the malady has not been consequent upon diarrhcea. When it super- venes during, or soon after, the eruption of any of the exanthemata, particularly scarlet fever, it is more or less inflammatory, and requires very de- cided treatment. Bleeding from behind the ears, or nape of the neck, should be carried as far as an attentive observation of its effects will indicate, particularly in children that have been well fed; and the rest of the remedies now advised, and especially the active enemata already directed, should be promptly, or even simultaneously, em- ployed. 278. In the sub-acute form of hydroce- phalus, a similar treatment to that which has been recommended for the acute, should be adopted early in the disease; vascular depletions being then practised, according to the circumstances of the case : and, when it seems disposed to pass into a more chronic state, small doses of iodine, or of any of its preparations, should be given during the day. A few grains of hydrargyrum cum creta, with digitalis, may be also taken at bed- time, and blisters be applied behind the ears, and kept discharging for some time. The bowels ought to be freely opened by the means already advised, especially the terebinthinate enema; and, in the latter stages, the same measures as have been directed for these stages in the more acute states of the malady, should be prescribed. If the disease assume a chronic form, the treatment about to be recommended (§ 297.) will then be necessary; but I have seldom seen benefit derived from any mode of treatment in such cases, prob- ably owing to the disorganisation that has taken place in the brain. 279. Diet, etc.—During the early periods of the disease, cooling diluents only, given fre- quently and in small quantities at a time, are required ; but in the latter stages, particularly when the emaciation and debility are consider- 676 DROPSY, CHRONIC, IN THE HEAD —Causes. able, suitable nourishment is necessary. If the child be still at the breast, the milk of the mother, or of a healthy nurse, in moderation; or asses' milk, beef tea, jellies, and the various farinaceous articles of food suitably prepared, are generally the most appropriate. During convalescence, the same kind of nourishment must be adopted for some time, but in more liberal quantities; and animal food should, at first, be cautiously and sparingly employed. Gentle tonics may also be exhibited, as a weak infusion of cinchona, or the compound infusion of roses. German writers pre- fer a weak infusion of valerian; and my experi- ence leads me to concur with them. Either it, or the infusion of cinchona, may be given with magnesia, which will render it less unpleasant, and gently aperient; and, if the urine be not sufficiently copious, a little tincture of squills, or ammoniated spirit of colchicum, may be added; or the compound infusion of roses may be taken with a neutral salt. In the latter stages of the disease, br during early convalescence, if the secretions and excretions be morbidly increased, suitable nourishment, as well as restorative medi- cines, should be administered more liberally than in other circumstances; but, in every instance, the influence of the diet and of the remedies, upon the pulse, the temperature of the head, and the general surface, ought to be carefully watched. Change of air to a warm and dry situation, or, in summer, to the sea side, will have a very ben- eficial effect, and should be adopted as early in convalescence as possible. 280. Prophylactic Treatment.—We are frequently consulted, iu the cases of children who are drooping in health, or who evince incipient symptoms of cerebral disorder; and even re- specting those who have no manifest ailment; but for whom, owing to the circumstance of one or several of the children of the family having had the disease, measures of prevention become absolutely requisite. The best of these are,— 1st, the increasing of the abdominal and cutane- ous secretions and excretions—2d, the establish- ing an artificial irritation and discharge; — 3d, strict attention to diet and regimen;—and, 4th, change of air.—(a) The evacuations should be carefully examined; and, when the bowels are sluggish, or the bile deficient, hydrarg. cum creta, or calomel, with rhubarb or jalap, should be given at bed-time, in gentle doses. James's powder should also be prescribed, whenever the skin becomes dry, either alone, or with small doses of calomel.—(b) Issues, moxas, or re- peated blisters, maybe employed, with the second object. Blistering behind the ear, the discharge being kept up for a considerable time, is very beneficial. Issues, either in the usual way, or by means of the inner bark of the mezereon, or scraped horseradish, will also be very efficacious. Dr. Cheyne refers to the circumstance of ten children in one family having died of the disease; the eleventh, for whom this means was employ- ed, having been preserved. The nape of the neck, the occiput, or the upper arm, are the most suitable situations for issues.—(c) Moderate diet, and that chiefly farinaceous, of a bland quality, and easy of digestion, is extremely requisite. All stimulating aliments or drinks; warm opiates, and too much animal food, are very injurious. Children should also be instructed not to retain any of the excretions, after the first intimations to evacuate them; and their limbs and trunk should be freed from all close cinctures. Prema- ture, or too great, exertion of their intellectual powers, particularly in forward or quick children, should be guarded against; and sufficient exercise in the open air should be imposed on them.— (d) In recommending change of air, the nature of the locality should not be overlooked. A dry, warm air is the most appropriate to hydrocepha- lic cases. ii. Chronic Dropsy in the Head.—Chronic Hydrocephalus. 281. Defin—Effusion of a limpid fluid in the ventricles, commendng previously to, or soon after birth; frequently with enlargement of the cranium; and generally either unaccompanied by acute symptoms, or supervening gradually, with signs of debility. 282. Chronic hydrocephalus has been stated above (§ 177.) to occur most frequently before birth, and sometimes to occasion the death ofthe foetus. Some females have given birth to a suc- cession of hydrocephalic foetuses, either dead or alive, at some time during the latter months of utero-gestation. In such cases, the effusion is usually connected with defective developement of the cerebral organs, and with some other mal- formation or congenital disease. When it comes on after birth, it either commences so insensibly as to escape notice, until far advanced, or it is attended by symptoms of increased excitability of the nervous system : it seldom is consequent upon the acute disease, or upon other maladies. Boehme and Wigand believe that an hereditary disposition to be affected by chronic hydrocepha- lus after birth exists in some children; and Rose- nstein, Struvk-, Loder, Goelis, andBRES- chet consider, that, when not congenital, it usu- ally begins a few days or weeks after birth, and very rarely after some months or years. It may, however, occur in old age. Goelis mentions a few cases of this kind; but they seldom are of long duration. Instances are not uncommon of considerable collections of fluid having formed in the ventricles of the brain, consecutively either of chronic diseases of the thoracic or abdominal viscera, or of prolonged affections of the brain itself, in persons far advanced in life; but these usually take place a short time only before death. 283. A. The Causes of chronic hydrocepha- lus are chiefly those assigned above as productive of congenital dropsies (§ 185.); family and con- stitutional predisposition, and a scrofulous and rickety diathesis. Goelis states the circumstance of a mother having had successively six dead- born hydrocephalic children-at the sixth month; and three which became hydrocephalic after birth; and J. P. Frank mentions another, who had seven children similarly diseased. The frights, passions, and diseases of the mother during gest- ation, have apparently some effect in producing this disease of the foetus; and weakness of con- stitution in either parent is evidently not without a similar influence. M. Breschet thinks that the old age of the father is an influential cause; and I believe that both it and drunkenness in the mother may be included in the enumeration. This writer states, that a drunken man of about sixty, married to a young and healthy woman, DROPSY, CHRONIC, IN THE HEAD —Varieties—Symptoms. 677 had three hydrocephalic children. Independently of diseases of the appendages of the foetus, some- thing, perhaps, may be imputed to the dress of the mother, particularly if it be such as may em- barrass the developement of the uterus; for it has been observed by several pathologists, particularly bones are firmly united. When the cranium is very much enlarged, the countenance presents a nearly triangular form, owing to the bones and the lower features of the face retaining their nat- ural size, or being smaller than usual. As the disease proceeds, the sutures are more and more Goelis and Breschet, that hydrocephalus has separated — sometimes so far as to admit of flue- occurred more frequently, either previously to, orltuation being felt, as remarked by Tulpius, soon after, birth, in the children of unmarried, Dreyssig, Monro, and others. The veins of than in those of married, females. Injuries expe- the neck become enlarged, (Lentin saw them rienced by the mother during pregnancy, and by varicose); the carotid arteries pulsate with much the infant during parturition; improper diet and force; and the head generally hangs on one side, regimen of the infant; exhausting affections of its or on the breast. Owing to the unequal yielding digestive organs; difficult, delayed, and disordered dentition, particularly when attended by disease ofthe prima via, and emaciation; as well as the causes assigned for the acute disease; may all oc- casion this species of it. Goelis states, that a physician in Vienna, an ardent admirer of the doc- trines of Brown, allowed his children wine and of the cranial parietes, some one part of the head is occasionally more prominent than another. The eyes are generally watery, covered by the eyelids; the pupils dilated, directed upwards,—occasionally downwards, (Feiler, Goelis, Schmidt),— and sometimes horizontally to either commissure of the eyelids. The senses, the intellectual facul- other stimulants from their birth; they all rapidly ties, and the locomotive organs and functions, be- became emaciated, and died with chronic hydro- cephalus. 2S4. B. Varieties.—Chronic hydrocephalus is most frequently idiopathic or primary; com- mencing during the latter months of foetal life, and sometimes after birth; and is occasionally consecutive or symptomatic of severe and exhaust- tray more or less disorder. Sight is first impaired, and all the other senses subsequently fail; the countenance is pallid and without expression; the complexion of the surface is unhealthy; the body emaciated; the gait unsteady; and the power over the muscles ultimately lost. 287. C. Symptoms. — (a) It is important to ing diseases of the abdominal or thoracic viscera. Iascertain the symptoms indicating the commence- It may be accompanied—(a) by a diminution of ment of the malady, in such cases as occur, or the size ofthe head, a variety which is always seem to occur, after birth. In many instances, congenital; the fontanelles being frequently closed, however, these are so slight as to be overlooked and the sutures united, at birth;—(b) by a normaliboth by the nurse and the physician; and the age size ofthe head;—and (c) by more or less increase! of the patient generally precludes many of them ofthe volume of this part.—u. In the first variety, jfrom being discovered. According to Goelis, the the head has a conical form, being depressed late- i nervous system is unusually excitable, the temper rally and anteriorly. The eyes are in constant irritable, and the sense of smell perverted. At this motion, insensible to the light, and the pupils period the eye is brilliant (Frank, Michaelis, dilated. Most of these infants die in convulsions, (Schoefff.r), but the sight soon becomes more either soon, or a few weeks after birth, and but and more imperfect. Vogel and Monro have very few live a few months, or a year or two. | noticed pains in the globe ofthe eyes, that subside Those who live so long are entirely deprived of as the effusion is increased. The nose is dry, sub- sense, and of every intellectual manifestation, jject to itching, and is frequently picked by the pa- Their appetite is generally voracious, but nutrition itient. Hearing is, at first, morbidly acute, sudden is very imperfect. Their legs are crossed and noises sometimes inducing convulsions; but it soon drawn up, and the feet distorted. The excretions becomes obtuse, and often altogether lost. Dis- are all involuntary, and life with them is entirely j charges from the ears are rare. The senses of vegetative. (touch and taste remain the longest. Rotation of 285. i. The second variety, or that in which >the head occasions vertigo, or stupefaction; and, the head is not materially increased in size, is sup-!if the fontanelles be not closed, pressure on them posed, by Goelis and Breschet, to be the most j produces convulsions, which sometimes supervene common; but I think that such is not the case J spontaneously at night. Sleepiness, or stupor; dull It may he congenital, or may appear any time; pain, or heaviness of the head; grinding of the teeth subsequently to birth. The writers now referred to believe that it is most frequent during youth and puberty, but that old age is not exempt from it. When chronic hydrocephalus occurs after the closure of the fontanelles, this necessarily is the form it most frequently assumes. Sei.le has termed it cephalic dropsy. The symptoms of this, are the same as those of the next variety. 286. •/. The third variety, or that with increased volume of the head, according to my own experi- ence, is the most frequent. It is very often con- genital, the size of the head even in the foetus being enormous. More commonly, however, the volume of the cranium is not much augmented at birth, but becomes so very rapidly afterwards. When the patient lives so long, the increase of size is slower after the third or fourth year, and ceases at the age of manhood, at which period the cranial 57* luring sleep, the patient sometimes uttering a pierc- ing or peculiar cry upon being awakened; and de- fect of memory; are also observed. Thus early in the disease, the appetite is often irregular or voracious; there is sometimes vomiting; the bow- els are commonly constipated ; and the urine diminished. Articulation is generally slow, nasal, or difficult. During this period, if the patient be old enough, he commonly is able to go about; but he is very feeble, and loses flesh. He walks, however, with great difficulty; totters; places one leg in the way of the other, and turns the toes inwards. Anger, and joy, are expressed with great vehemence; and the mental manifestations are more or less weakened or deficient. Such is the first period of chronic hydrocephalus; but it most frequently comes before the physician when the second stage has supervened. 62 678 DROPSY, CHRONIC, IN THE HEAD —Symptoms, etc. 288. (b) Schmalz, Feiler, Goelis,. and others, consider the copious flow of saliva from the mouth—which is always open—as indicating the second stage of the disease. When the patient can speak, he is now at a loss for words, or forgets them as he is about to utter them, and his voice is sad and monotonous. He is no longer able to go about; and is often sick. The bowels continue sluggish, and the urine scanty. The erect and sit- ting postures are attended by retchings, or vertigo, or pain in the head and stupefaction. The pupils are dilated; sight is more or less completely lost; the eyes roll from side to side; and squinting is|Baron, Buttner, and Miller respectively fifteen, seventeen, or twenty inches in circumfer- ence. Wrisberg records an instance in which it reached thirty inches and a half. , Meckel has in his museum the skeleton of a hydrocephalic foetus of seven months, the horizontal diameter of whose cranium is sixteen inches, and the vertical diameter—from the occipital hole to the vertex— fifteen, being a circumference of forty-eight inches. And cases in which the head had acquired the vol- ume of seventeen, twentyrfive, twenty-nine, thirty, and thirty-one inches, soon after birth, have been recorded by Lechel, Malacarne, Willan, sometimes observed. The pulse is small, irreg- ular,- and occasionally intermittent. Respiration; which was, in the first stage, scarcely affected, is often somewhat difficult, in some cases suffocative, and attended by a nervous cough. The position is often with the head very low, or drawn back- wards; or upon the abdomen, with the face sunk in the pillow (Feiler and Breschet); and automatic movements of the limbs are frequent. Deglutition becomes difficult; but the appetite is still unimpaired, or even increased. All the senses and mental powers are more or less injured, or nearly lost. 289. (c) The third and last period may be said to commence with the involuntary discharge of the excretions, and abolition of all the senses; the pa- tient lying with the lower limbs paralysed, or drawn up to the abdomen. Towards the close of! pects. It is only, however, the cranial part of the head which is thus distended; the bones of the face generally retain the natural size, or are developed in an inferior degree, especially in those cases which are prolonged to, or which pass the period of, puberty. The only instance in which the con- trary was observed, is recorded by Hartell,— the bones of the face having in that case acquired such a size as to resemble those of a giant. The form of the head is often not materially different from that of the foetus; but, as the collection be- comes greatly increased, it commonly extends in the direction of those parts where ossification is the least advanced. In some cases, one side either is more elevated, or is protruded more anterior- ly or posteriorly, than the other, or both, the cranium assuming an oblique form in all its as- the malady, the extremities become cold, damp and often cedematous; the whole body extremely emaciated; and, if the patient has all his teeth, they are frequently worn to the stumps by the 292. (/) The Duration of the disease varies extremely. It has already been stated to termi- nate fatally in the fcetus at any time during the latter months of pregnancy, or immediately, or constant grinding of them in the early stages.! shortly, after birth. Whether it commence previ- Ultimately, either the symptoms of acute hydro-1 ously, or subsequently, to birth, its duration may cephalus, sometimes with convulsions, or those be indefinitely prolonged from some weeks to a of apoplexy or coma,come on, and terminate life.' number of years. Hartell, Malacarne, Mil- Occasionally the patient is carried off by a pa- ler, and Goelis adduce instances of hydroceph- roxysm of convulsive or suffocative cough. Thejalic patients having lived seventeen years; Loder duration of these periods, especially the second mentions one aged twenty-two years; Breschet, and third, is extremely uncertain; and not iiifre-! another who was twenty-eight; Michaelis saw quently very prolonged. ja case aged thirty; Buttner, one at thirty-one; 290. (d) Such is the usual progress of the Schneider, one at forty-three; Aurivill, an- disease, especially when it has seemed to have! other at forty-five; Schomberg, an instance of its commenced after birth. But in these, as well as'having been prolonged to forty-eight years; and in such as have been congenital, modifications or Gall, another, where life was prolonged to fifty- anomalies present themselves. The senses and four years. A patient died a few years ago, in intellects may be quite unimpaired; or certain'GuY's Hospital, at the age of thirty-two years: Benses or faculties, only, may be impaired or lost,'his head was thirty-three inches and a half in although the head is remarkably enlarged. The circumference ; his appetite and digestion were moral emotions, in such cases, are sometimes af- undiminished; and his mental powers not much fected; the patient being passionate and vindictive; impaired. Walking induced vertigo; and costive- and fits of anger often excite convulsions. The ness, convulsions. Coma came on a few weeks sexual organs are sometimes prematurely develop- before death, and passed into fatal apoplexy. ed, and the venereal desires strong even in chil-l 293. D. Appearances on Dissection.— dren of both sexes. Great differences also .exist as The cranial bones are generally found very thin, to the closure ofthe sutures and fontanelles; which flexible, sometimes transparent, occasionally wider very frequently remain much longer open than than usual; and the osseous fibres imperfect and natural, especially when their separation has been ] radiated. In very young subjects, the bones are considerable. Cavallini mentions a case, in'separated from each other by a greater or less which the fluid continued to ooze from between interval; which is filled up, "in somewhat older the sutures for some time before death; and Dr.leases, by distinct points of ossific deposit, which Baron and Mr. Miller have recorded instances' ultimately constitute the ossa Wormiana. In rarer wherein it dribbled from the nostrils, the dura'instances, the bones are thicker than natural, as in mater having been ruptured, some days or weeks those recorded by Hartell, Reidlin, Albi- before dissolution. |nus, Mollineux, Sandifort, and Loder. 291. (e) The size ofthe cranium is sometimes The ossa Wormiana are, at first, scarcely in contact enormous, both previously, and subsequently, to j with the margins of the normal bones; but when birth. It is frequently, iu the fcetus, increased to the case has been protracted, they fully occupy the DROPSY, CHRONIC, IN space, and ultimately become indented into, or nearly consolidated with, them. Entire obliter- ation ofthe sutures is very rare. The fluid is ge- nerally effused in the ventricles,—always when the disease commences after birth; and but seldom in the general cavity of the arachnoid, excepting in the congenital disease; when the ce- rebral hemispheres are sometimes either partially or entirely wanting, the base, the pons Varolii, &c. only existing. When much fluid is effused into the ventricles, the brain is distended, its convo- lutions are unfolded, and it is reduced to a sac, thin in proportion to the distension; its structure with difficulty, or not at all, admitting of being distin- guished into cineritious and medullary substance. The corpus callosum is much raised, and thin- ned, and the septum lucidum torn; the lateral ventricles communicating freely with the third, and this with the fourth, the whole forming one cavity. The cineritious substance is of its usual consistence; but the medullary is generally firmer than natural. The brain, however, does not appear to be diminished by interstitial absorp- tion, as its weight is not materially less than the healthy brain at the same age. The arachnoid is occasionally whitish, opaque, and in some places thickened. The choroid plexus often con- tains small cysts; and the corpora striata, as well as the thalami optici, are small and flattened The parts near the base of the brain, in some cases, present only slight alterations, varying with the duration of the disease, and the extent of the effiision; and, in other instances, they are so much changed, as hardly to be distinguished the one from the other. The cerebellum is seldom materially altered. The quantity of fluid varies from ten or twelve ounces to as many pounds; and cases are recorded of as much as ten or twelve quarts having been found. Ft bricius Hilda- nus (cent. i. obs. 10.) found eighteen pounds; and Bonet (Sepulchret. I. i. sect. xvi. obs. 11.; see also Ephemer. Nat. Cur. dec. iii. an. i. obs. 10.) twenty-four pounds. The analyses of Bostock, Marcet, Barruel, Berzelius, and John, agree in showing that this fluid is of the lowest specific gravity, and contains the smallest quantity of albumen, and of saline ingredients, of all the dropsical fluids (§ 11.). Although, in the con- genital form of hydrocephalus, the formation of the brain may have been so early arrested, as to occasion the absence of a great part, or of the whole, of it, yet its envelopes—the cranial bones, the dura mater, the arachnoid, and even the pia mater — may exist nevertheless. In some cases, the falx cerebri is wanting (Breschet), and, according to some authors, the pia mater also; yet it seems to be generally present, but so thin, from the distension of the fluid, as to be detected with difficulty. The arachnoid is more dense, and less transparent, than natural. 294. In the case that occurred, some years ago, at Guy's Hospital, upwards of ten pints of fluid were contained in the great sac of the arachnoid, with which the ventricles communicated freely, the corpus callosum being wanting. The brain was lodged at the bottom of the immense cranial cavity; was "somewhat flattened; and its con- volutions unobliterated and unfolded. In a case recorded by Dr. Baron, the dura mater was found ruptured; a tumour of the cranial integu- ments having taken place over the seat of rupture THE HEAD —Prognosis. 679 some time before death. In a case described by Dr. Duncan (Trans, of Med.-Chirurg. Soc. of Edin. vol. i. p. 205.), the dissection of which was made by Dr. Gordon, the circumference of the head was twenty-nine inches and a half, and the fluid was contained in the general sac of the arachnoid, with which the ventricles freely com- municated; the corpus callosum and fornix being entirely wanting, as in the case noticed above; the brain thus having a bifid or cleft appearance. A nearly similar instance is recorded by Mr. Loft if., in the Medical Observations and Inqui- ries (vol. v. p. 121.). In the one published by Mr. Miller (Trans, of Med. and Chirurg. Soc. of Edin. vol. ii. p. 245.), the dura mater was rup- tured, and water seemed to have been lodged be- tween it and the cranial bones, as well as in the general sac of the arachnoid. But it seems pro- bable, from the appearances observed, that the fluid had been originally in the ventricles, from whence it had escaped by a lacerated opening, caused by their uncommon distension; nearly nine pints of fluid having been found. 295. Chronic hydrocephalus, especially the congenital, is often associated with other vices of conformation (Meckel, Osiander, Murray, DESLANDF.S,OTTO, At'TENRIETH, BrESCHET, &c); as with cleft palate, single or double hare-lip, spina bifida (§ 178.), imperforate anus, distorted or club foot, and absence of one or more of the abdominal viscera. 296. E. Prognosis.—When the disease is congenital, as it most frequently is, even although it may not become manifest until some days or weeks after birth, or when it appears soon after birth, little or no hope of benefit from treatment can be entertained; for, in such cases, it is often dependent upon imperfect or arrested develope- ment of the brain. When, however, it is either ob- viously, or very doubtfully, not congenital, I agree with Richter, Dreyssig, Blane, Porten- schlag, Goi.lis, Conq,uest, and some others, in considering that it often admits of cure, par- ticularly if it be treated early, if it be uncom- plicated, and if the powers of the constitution be not much impaired. J. P. Frank states, that he has seen it disappear upon the occurrence of ! scrofulous disease in another part. Goelis and j most other writers have seen more or less advan- tage accrue from spontaneous eruptions and sores, I particularly behind the ears, and from chronic [ discharges from the bowels and skin, if they do not much reduce the patient's strength. When the disease occurs in those of a manifestly scro- fulous or syphilitic taint; or follows the acute; i or is far advanced; strangulating cough, difficult [ or suffocative respiration, coma, frequent con- vulsions, delirium, or other symptoms of the last period being present; hardly any hopes of recovery should be entertained. The exanthemata or hooping cough occurring in its course, generally induce a fatal termination in a short time. Its complication with hydrorachis, or with other forms of dropsy, is also very unfavourable. j 297. F. Treatment.—The indications of cure j are,—1st, to subdue irritation in the encephalon, | when the symptoms of the first stage indicate its existence; 2d, to counteract the disposition to aqueous effusion into the ventricles; 3d, to remove the fluid, and prevent its re-circulation; and, 4th, to palliate urgent symptoms.— a. The first of 680 DROPSY, CHRONIC, IN THE HEAD —Treatment. these intentions applies chiefly to those cases which occur subsequently to birth, and when evidence of nervous excitement or vascular irri- tation can be detected. In such cases, one, two, or more leeches, according to the age and strength of the infant, should be applied behind the ears, and means used to derive the irritation to some part of the cutaneous surface, or to the intestinal canal. In the majority of instances, the same measures as will subdue irritation, will also tend to the fulfilment of the second indication; more especially mercurials, aperients, purgatives, and artificial eruptions and discharges. In the use of this last, much circumspection is requisite; for tartar emetic ointment, or blisters kept open, may produce sloughing sores in young and delicate children. 298. b. To fulfil the second intention, various measures have been recommended.— a. Goelis places most reliance upon small doses of calomel, — from a quarter to half a grain twice a day; and on the mercurial ointment applied to the head, either alone or with an ointment of juniper berries. He advises a flannel cap to be, at the same time, worn constantly upon the shaved scalp, to promote the insensible perspiration. This covering, in a few days, becomes charged with the ointment or ointments employed, and thereby tends to bring the system more quickly and fully under the influence of mercury. But affecting the constitution with mercury will rarely remove the disease; and, in very weak children, will only reduce more rapidly the powers of life, to which we should chiefly trust, as the more im- mediate agent by which this indication is to be fulfilled. My experience leads me to confide more in the hydrarg. cum creta than in calomel, in most cases of this disease. The best part of ' the treatment resorted to by Goelis is the daily j use of mildly stimulating baths. I have seen considerable advantage derived from them, es- pecially when those first employed contained an alkali. Various tonic, astringent, diuretic, or slightly stimulating substances or infusions may be directed in this manner; as well as the pre- parations of iodine, or the nitro-muriatic adds, in very weak solution. M. Recamier states, that benefit has been derived from baths holding tartar emetic in solution; this substance being gradually increased to three or four times the quantity first employed; and that it acts as a diuretic. 299. In those cases, especially, which have commenced after birth, all morbid secretions and faecal accumulations having been removed from the prima via, by purgatives and cathartic enemata^ from one to two or three grains of hydrarg. cum creta should be given night and morning, and the scalp shaved. If the head be quite cool, and without signs of vascular excitement, it should be kept moderately warm, and washed daily with a weak, tepid solution of the nitro muriatic acids; the baths now recommended being also.employed. This treatment, with proper diet and regimen, should be tried for some days, especially in deli- cate children; but in those who are stronger, it is preferable to exhibit, once, twice, or thrice a day, from five to ten or twenty minims of oleum tere- binthinae, with from twenty to forty or fifty of oleum ricini, according to the age of the patient, and effects produced upon the bowels and urinary organs. For infants, these oils may be mixed in syrup; but, by older children, they will be most easily taken on the surface of fennel water, or of milk. When this medicine does not act fully on the bowels, it may irritate the kidneys or produce l strangury. In this case, it should either be inter- I mitted for a few days, or given in larger doses, at longer intervals—or sometimes only twice or thrice a week — so as to act as a gentle purgative. An enema containing from one to four or five drachms of each of these oils, according to the age of the child, may also be administered every third or fourth day, in a suitable vehicle, either in addition to the above medicine, or when it is not prescribed; and the liniment F. 311. may be rubbed once daily upon the loins, or over the shaved scalp, the head being covered by a thin flannel cap. The hydrarg. cum creta should also be taken night and morning; and, if these oils be not employed so as to act sufficiently upon the bowels, as they ought, a full dose of calomel, or an active ca- thartic, should be occasionally given at bed-time. The above treatment was, for thirteen years, very generally adopted by me in chronic hydrocepha- lus, at the Infirmary for Children; and, in many instances, with marked success. 300. ;?. In other cases, particularly in private practice, and where the measures now detailed are not regularly pursued, owing to their unplea- sant nature, a course of iodine should be entered upon, and continued for some weeks; but the pre- parations of this substance ought to be exhibited in doses which will not gripe or otherwise irritate the digestive canal; the alterative mercurial being taken at bed-time, and an occasional cathartic, or a terebinthinate enema, administered in the morn- ing, during the course. If evident advantage follow not the iodine within a fortnight or three weeks, a liniment (F. 302.) or ointment (F. 767 —769.) of it, or an ointment of the ioduret of mercury, should be rubbed upon the head twice or thrice a day. If it occasion irritation in the scalp—which will seldom be the case with the preparations now referred to — the circumstance need not be considered unfavourable. If the internal course of iodine be not adopted, gentle aperients and diuretics, with mild tonics, should be taken in the course of the day. The above plans of treatment I have found more successful than any other; but they require great discrimin- ation, and nice adaptation to the circumstances of the case :— that by the terebinthinated medicines has appeared most beneficial in the stronger chil- dren; and, whilst it has acted freely on the bowels, it has often greatly increased the quantity of urine : that by iodine is better borne by delicate children, but its operation is slower, than the former. The mouth sometimes becomes affected by the mercurial preparation during either of these courses, particularly in the older children; but this is to be viewed as a favourable occurrence. As long as the powers of the system continue but little impaired, and the patient does not lose flesh, either the one or the other course should receive a full trial; light and suitable nourishment being given, and the bowels kept freely open, always avoiding the supervention of diarrhoea. 301. •/. When these internal and external means fail of affording evident benefit in a few weeks, or when they cannot be satisfactorily tried, blisters should be applied, or issues inserted behind the ears, or over the occiput; and tonics, with laxatives and DROPSY, CHRONIC, IN THE HEAD — Treatment. 681 diuretics, exhibited internally. Of these last, the acetate of potash, with oxymel of squills; and the spiritus atheris nitrici, with a small addition of ni- tric acid; are amongst the best, and should, in the more debilitated, be given in tonic infusions. After the mercurial alterative has been continued suffi- ciently long, and the modes of treatment now detail- ed have beeu fairly but ineffectually tried, a very weak solution of the nitro-muriatic adds; or of the hydro-chloric acid, with the chloric ather; or of the aromatic sulphuric acid, with Hoffmann's anodyne; may be prescribed internally: but the exhibition of mercurials should be fully relin- quished, and their effects satisfactorily ascertained, before any of these be taken, otherwise very seri- ous disorder ofthe stomach and bowels may be oc- casioned by them. A succession of blisters to dif- ferent parts of the head, the one side or part being allowed to heal whilst the other is discharging, is sometimes serviceable; but the blisters should not remain on after they have produced redness of the part, and the practice should be persisted in for some time. 302. o. If acute symptoms supervene in the course of treatment, leeching or cupping, some- times followed by dry cupping, and generally by calomel, and active purging, must then be resorted to appropriately to the strength of the patient, with such of the measures recommended for the acute disease, as the peculiarities of the case may require. 303. f. If debility, languor of the circulation, and flabbiness ofthe soft solids, be considerable, in addition to the hydrargyrum cum creta, as advised above, the powder or infusion of calumba, or of cascarilla, or of valerian, or of dnchona; or small doses ofthe sulphate of quinine, or ofthe sulphate of iron, with the neutral sulphates — as the sul- phates of magnesia, soda, or potass ; or the sul- phate or oxide of zinc; will be sometimes bene- ficial early in the second stage. The ferrum tartarizatum also should not be overlooked in the treatment of these cases. I have lately seen the ioduret of iron of service in two such instances. Several years ago, the oxide of zinc, or the sub- nitrate of bismuth, was frequently prescribed by me, in doses which would not offend the stomach, either alone or with mild vegetable tonics, and taken during the day; the mercurial alterative being continued night and morning, and a tere- binthinate enema exhibited twice in the week. Some patients certainly improved, or recovered, under this treatment. But as most of these cases occurred in dispensary practice, the result in several of them was not ascertained. During the exhibition of tonics in chronic hydrocephalus, the secretions and excretions — both abdominal and cutaneous —ought to be freely promoted by means of slighty alkaline baths, and laxatives, otherwise the disease may assume an acute form, or pass rapidly into the third and irremediable stage. 304. ". Warm and other diaphoretics are directed by several writers: Hopfengartner advising the flowers of arnica, and serpentary root; and Dr. Temple, the doronicum Germanicum, with the more common medicines of this class. Digitalis, and the internal use of cantharides, are recom- mended by many respectable authorities. These two may be conjoined; for the former vyill be given, with greater benefit, in this state of disease, with tonic infusions and stimuli, than in any other combination; but its ettects must always be care- fully watched. The internal use ofthe muriate of baryta and muriate of lime is suggested in the more manifestly scrofulous cases, by Auti-.nrieth. The repeated exhibition of irritating enemata is enjoined by Mkllin and Michaf.hs, and has proved of great benefit in my practice, particularly the one already named (§ 299.). Sialagogues are favourably noticed, especially by the older authors. They deserve more attention than has been lately paid to them, and are certainly useful adjuvants, especially about the period of dentition, when the gums and teeth should be frequently examined ; irritation ofthe former being removed by indsions. — Errhines are also prescribed, particularly by Heister, Forestus, and Mondschien. 305. t,. Various applications—some of them the most opposite in their natures and effects — have been directed to be applied to the head, with the view either of promoting exhalation from its surface, and thereby transferring this action from the interior of the head; or of diminishing effusion in this situation, by restoring the healthy action of the capillary and exhaling vessels. Blancard and Fabricius recommend that the head should be kept warm by bladders filled with hot sand, or by sponges squeezed out of hot water; and Mond- schien, that bags containing either unslacked lime, or roasted salt, be applied to it. Boerhaave, Borsieri, and Hecker advise fomentations with aromatic wines; Flajani, Plenk, Itard, and Kleber, epithems with the wine or vine- gar of squills; and Psab, Deleurye, and others, dry fomentations with warm aromatic plants. Zwinger, Sorbait, and Mellin direct the ! scalp to be rubbed with ointments containing the etherial oils, especially the oil of turpentine or naph- [ tha with alchohol; and Perdulcis, Johnstone, Monro, &c. favour the use of woollen caps which have imbibed the essential oils. Besides these, a variety of pias£e-rs,especially such as pos- sess a deobstruent and tonic quality, are mentioned by writers. Of this class of means, the plasters F. 116, 117, 118. and the liniments F. 300. 311. are the most efficient. Acrid applications, and scarifications of the scalp, are likewise noticed by Heister and Diemerbroeck; and the actual or potential cautery, and moxas, by Chesneau, Tan a ron , and several other Continental authors. 306. &. Gentle and continued compression by bandages is recommended by Rive rius, Fo rmet, Pi tsc hel,Bl a ne, and Hood; and has manifestly been of service in some instances. Compression by means of strips of plaster, composed of equal parts of the emplastrum picis comp., and of the emp. ammoniaci cum hydrarg., or of these and the emplast. cumini, and spread on stiff linen, has been found by me preferable to the common method by bandages, and has commonly been employed in addition to the means detailed above (§ 298. etseq.). The plaster, thus composed, should be cut into slips; and, whilst each should partially surround the head, the number applied ought to be sufficient to cover the whole scalp, which must be kept closely shaven. In the case treated by compression, by Sir Gil b ert Blane, leeches and purgatives were also employed; and a favour- able termination resulted. Mr. J. F. Barnard resorted to pressure successfully in nearly the same manner as I have now advised, and used for the purpose broad strips of adhesive plaster. He also kept the head covered by linen wet with cold 682 DROPSY, CHRONIC, IN THE HEAD —Treatment. water; a practice whichshould not be omitted when- ever the temperature of the head rises above natural. 307. c. The removal of the fluid by puncture has been recommended from H i p p o c r at e s to the present time. But it has never been practised with success until recently; and it is doubtful whether some ofthe cases which have been said to have recovered by the operation, have ultimately been cured. Indeed, great difference of opinion has existed as to the propriety of performing it. Le Cat, Junker, Sorbait, Remmett, and many recent writers, have advised and practised it; whilst Heister, Boerhaave, Morgagni, Monro, Borsieri, Mercati, Richter, Flajani, Portenschlag,Goelis, Breschet, Heck- er, &c. are opposed to it, on the grounds that it has never cured the disease, but has often accelerated a fatal termination. After the medical treatment above detailed has been appropriately, sufficiently, and ineffectually tried, this operation, as it is not attended by any immediate risk, when cautiously performed, may be resorted to. In such circum- stances, I have concurred in it, where it has been, in several instances, performed by my able col- league, Mr. D e n d y , at the Infirmary for Children; but I recollect no case in which it has ultimately succeeded, although the management of the cases could not have been in more experienced hands. Many ofthe older writers, who advised the operation, conceived the water to be collected in the sac of the arachnoid, and not in the ven- tricles, and, consequently, that, in making the puncture, the cerebral substance would not be penetrated; but such is not often the case. In- stances of its performance are adduced by Tulpi- us, Fabricius Hildakcs, De La Motte, Pe- tit, Wepfer,E. Ferdinand, G. Fabricius, D. PANAROLius,andseveralrecentwriters. The following is a brief notice of those which are the most instructive. 308. a. Le Cat (Philosoph. Trans, vol. xlvii. p. 267.) operated on a child three months and a half old, affected subsequently to birth, thrice in three successive days; death occurred on the fifth day after the first puncture. The pineal gland was found nearly destroyed, and the ventricles much expanded. Dr. Oppenheim (Rust's Mag. fur die Gesammte Heilk. b. xxiv. 1827.) operated on an infant of seven months with a trocar, leaving the canula in the puncture. It died on the seventh day. The membranes were somewhat thickened, and the brain soft and pulpy. Dr. Whitmore (Amer. Med. Recorder, July, 1821.) punctured the head of an infant of six montlis, hydrocephalic after birth; and in eight days withdrew, without a canula, 116 ounces. Death followed on the tenth day, the membranes being found inflamed. Dr. Hood (Edinburgh Med. and Surg. Journ. Oct 1821.) operated on a child of nine months by* a trocar. Death took place on the third day. The brain was soft- ened and the tubercula quadrigemina were sup- purated. Mr. Dendy (Lond.Med. Repos. vol. xix. p. 446. operated on a congenital hydrencepha- locelic case, aged ten weeks, with a large, deeply grooved needle, and removed eight ounces at three operations, with three days interval between each. Death occurred on the tenth day. The ■fluid was lodged in the left ventricle, over which the brain had not been formed. The membranes were found inflamed, and the brain surrounding the effused fluid softened. Mr. Brown (Med. and Phys. Journ. vol. Ii. p. 102.) punctured the head of an infant of five months, on five occasions, in the course of thirty-six days. The last puncture was followed by great haemorrhage and dissolution. Mr. Gray (Ibid. vol. liv. p. 204.), from a child whom he had cured of spina bifida by compres- sion, but who became hydrocephalic soon after- wards, drew off forty-five ounces of fluid at three tappings. The symptoms were mitigated for a time; but death followed on the thirty-first day. Dr. Freckelton employed five successive punctures with a trocar, in the course of fifty-six days. Death occurred on the fifty-ninth day. Mr. Callaway (Amer. Med. Recorder, July, 1821.) operated on an infant five weeks old, and repeated the punc- tures on four successive weeks; but it died of ma- rasmus and gradual exhaustion on the seventieth day. Mr. Remmett (Edinburgh Med. Comment. vol. vi. p. 422.), in a congenital case, punctured the head with a lancet, two months after birth; and in the first six days, on three occasions, drew off thirty-six ounces in all. He repeated the operation twice subsequently, with a month's in- terval between each. The infant died of atrophy ninety-three days after the first puncture. On dissection, the fluid was surrounded by the mem- branes; the rudiments merely of a brain, in a softened state, being lodged at the bottom of the cavity. Mr. Money (Med. and Phys. Journ vol. Iii. p. 462.), operated on a congenital case ten months after birth, by a small trocar, on ten different occasions, during seventy-four days. The child died on the eighty-fourth day after the first operation. The membranes were inflamed, and the brain dilated into a large sac. Mr. Sym (Edin. Med. and Surg. Journ. vol. xxiv.), in an infant of eleven weeks, punctured the head, and repeated the operation five times in the course of ninety days, withdrawing about seven ounces of fluid each time. Death occurred on the 104th day. The arachnoid was thickened. The fluid was contained in its general cavity, and the brain im- perfectly developed. Dr. Glover (New York Med. Repos. vol. iv.) operated in a congenital case, nine months after birth; and, in four months, withdrew 156 ounces at eight tappings; but death took place, after a considerable period of amendment, on the 120th day. Mr. Lizars (Edinburgh Med. and Surg. Journ. April, 1821.) operated on an infant four months old; and in the course of 90 days repeated the puncture fifteen times, at intervals of from three to seven days, taking away each time from three to ten ounces of fluid. The child did well until convulsions oc- curred during teething; and the head was again enlarged. Puncture was again tried; but it died on the following day, and on the 171st after the first operation. Dr. Vose (Med.-Chirurg. Trans. vol. ix.), in a congenital case, operated seven weeks after birth, and thrice subsequently, at considerable intervals. The sutures afterwards Ossified; and, three months later, when he pub- lished the case, the child was doing well. Dr. Mo n ro, however, states (Morbid Anatomy ofthe Brain, Src. p. 146.), that symptoms of pressure appeared after the sutures were ossified, and the child ultimately died. 309. (I. Mr. Greatwood (Lancet, No. 299. p. 238.) records a case of a hydrocephalic child of fifteen months, who, falling on a nail, punc- DROPSY, CHRONIC, IN THE HEAD —Treatment. 683 tured the head at the upper third of the lamb- doidal suture. The wound continued to dis- charge fluid for several days, and it afterwards perfectly recovered from the disease. In the same work, for April and November, 1830. the operation of puncture is stated to have been successfully performed in St. Bartholomew's Hos- pital. Graefe (his Journ. for 1831, b. xv. p. 3.) punctured the head of an infant hydro- cephalic from birth, in the fourth month, and re- peated the operation about eleven times during six months. The fluid was allowed to escape slowly each time ; the canula being removed, and the wound closed, as soon as the pulse became weak. After the last puncture, the sutures closed. The child could walk and speak when a year old. At the age of two years and a half, it was shown to the Medico-Chirurgical Society of Berlin. Mr. Russel (Edin. Med. and Surg. Journ. July, 1832, p. 43.) operated on a girl eight months old, hydrocephalic from birth, and whose head was twenty-three inches in circumference when he first punctured it. The operation was repeated four times, after intervals of about ten days ; but the quantity of fluid withdrawn each time was small. After the last puncture, calomel was given so as to affect the mouth; when the hydrocephalic symp- toms disappeared, and ossification of the sutures proceeded. The case is stated to have been cured. Dr. Conquest is reported, in a con- temporary work, to have operated in nine cases, — successfully in four of them. The greatest number of punctures in one case were five, and the intervals between them from two to six weeks. The largest total quantity of water removed was fifty-seven ounces, by five operations ; and the largest quantity at one time, twenty ounces. The trocar was introduced through the coronal suture, below the anterior fontanelle, and the wound care- fully closed after each evacuation. Pressure was made by means of strips of adhesive plaster. 310. The cases in which I have been con- cerned in directing the operation, have all been unfavourable to its success. Medical treatment had been actively and perseveringly employed in all of them; and it is therefore probable, that such of them as admitted of recovery were amongst the number that was cured. Whilst in those in which the operation was resorted to, and winch were mostly congenital, either the state of the brain and its envelopes precluded recovery, or the oircumstances in which out-door patients of public charities are placed were such as to render this operation less successful than it otherwise might have been. 311. y. Having stated the evidence we at present possess ofthe success ofthe operation, inferences as to the propriety of performing it may be easily drawn. Those who argue against it contend —(a) that it is apt to induce an irritative stato of inflam- mation in the substance or membranes of the brain, particularly in the weakened and otherwise predisposed systems of such subjects—1st, by the mechanical injury done to those structures; and 2dly, by the entrance of air through the punc- tuce;—(b) that the collapse consequent upon the removal of the fluid is injurious to the organ and system; — (c) that the operation cannot change the state of the organ or function giving rise to accumulation; and hence that it cannot be permanently successful;—and (d) that the in- stances of success from it are not so numerous as those from medical treatment. 312. Those in favour of the operation, on the other hand, argue—(a) that greater injury than that by the puncture is often done to the brain and membranes, without bad consequences;—(b) that the air may be prevented from entering by the aperture ; —(c) that danger from collapse is readily obviated ; —(d) that cures from medical treatment, in an advanced stage, and when the head has become greatly enlarged, are very rare, and are then most likely to be obtained by an oper- ation ; —(e) that the instances of success on record are sufficient to warrant its performance. 313. <5. From much experience, I conclude that inflammatory irritation of the brain and its mem- branes does follow the operation in some instances; that the state of these parts, and of the system, favours its occurrence; and that the encephalic structures are in a very different condition in this disease, both mechanically and vitally,— but es- pecially as to proneness to inflammatory action, and softening,— from what they are in health. — (a) Whilst, therefore, I so far agree with those who argue for the operation, as to advise it to be tried after the measures I have detailed above have failed, yet I would not recommend its perform- ance early in the disease — 1st, because medical treatment has then sometimes effected a cure, es- pecially when the head has not been very greatly enlarged; and, 2dly, because, when the fluid is in the ventricles, as it generally is in cases com- mencing after birth, a greater depth of brain must be penetrated to reach it at an early, than at a later, period.—(6) When punctures are resorted to, medical treatment must not be abandoned, or even relaxed; for we should still endeavour, according to the principles explained above, to remove the disposition to effusion, as well as to promote absorption; and, as a certain degree of pressure is requisite to the healthy performance of the cerebral functions, strips of plaster, as are already dirrected (§ 306.), should be applied around and over the whole scalp, in order to pre- vent the collapse consequent upon the operation.— (c) I believe that the punctures ought not to be fre- quent, nor much fluid withdrawn at one time; that gentle pressure should be made around the cranium during the discharge; that the dis- charge ought to be stopped, and the puncture accurately closed, so as to prevent the entrance of air, as soon as the pulse begins to sink; and that restoratives should be exhibited, in order to prevent convulsions, or other nervous symptoms.— (d) The operation seems to be best performed by a small trocar, or grooved needle; but it is difficult to withdraw any fluid with the latter, as the sur- rounding pressure fills up the groove. The appli- cation of a cupping glass may, however, procure a discharge. A thin trocar, with a two-edged or lancet-shaped extremity,— not a thick triangular pointed instrument, — is preferable, upon the whole. 314. d. Urgent symptoms, especially convul- sions, and inflammatory action, require to be palliated or removed.— «. Convulsions should be treated according to the manner described in that article, particularly by the terebinthinated me- dicines and enemata already prescribed (§ 299.); by these, conjoined with the syrup of white poppies, or this latter with the oxide of zinc; by 634 DROPSY, CHRONIC, IN THE HEAD —Treatment. foetid enemata; by cold or tepid affusions on the head; and by dry cupping on the nape of the neck, or between the shoulders.— /?. The appear- ance of acute symptoms requires the treatment stated above (§ 302.); with mustard pediluvia, or mustard poultices to the legs and thighs; cold affusions and applications to the scalp, &c.— y. In the third stage, the disease is generally beyond the influence of medicine; the disorgan- isation which has then frequently taken place in the encephalon not admitting of restoration; and it is chiefly in it that the palliation of urgent symptoms is required. But little beyond the fulfilment of this intention can then be attempted, unless puncture be resorted to as a last resource. 315. e. Diet and regimen form no unimportant part of the treatment. The diet should be light and nutritious, and care should be taken not to allow the patient to eat so much at a time as to load the stomach. For infants, the milk of the nurse is sufficient; but she should be healthy, and fed upon digestible and nutritious food, and her bowels carefully regulated. Children who are weaned should have a small quantity of animal food; and be debarred from all acescent vege- tables. Change, particularly from the close parts of a city, to a country air, which is warm and dry; and frequent exposure to the open air and to sunshine, in mild weather, are very serviceable. Many children have ravenous appetites, espe- cially as the disease advances ; these require sufficient nourishment, but more than that is injurious. In these cases, the terebinthinated medicines, more than any others, allay the insa- tiable craving, symptomatic of the malady, and tending to aggravate it when indulged; whilst they exert a very favourable influence on the disease. The drink allowed to the patient should be or- dered with strict reference to the treatment pur- sued at the time, and should be as much as possible adjuvant of it. 316./. The prophylactic Treatment may be comprised in a few words.—When any one of a family has had the disease, particularly if there exist a scrofulous or rickety diathesis, the state of the secretions and excretions ought to be carefully watched, and the earliest deviation of them from health combated by appropriate means. Cuta- neous eruptions should not be interfered with, un- less with great caution; all external medicaments to them should be avoided, and internal remedies, of an alterative, deobstruent, and diuretic kind only, be prescribed. The skin ought to be kept clean and perspirable. External injury of the head, and premature exertion of the mental facul- ties, must be avoided. Free and daily exposure to the open air and sunshine; moderate, light, and suitable diet ; an open state ofthe bowels; a healthy nurse, whose mind is not liable to anxiety; and what has been already advanced above (§ 279, 280.); are all requisite to the prevention of the malady, particularly under the circum- stances alluded to. ,Bibliog. and Refer.—Hippocrates, flint vovoatr, ft . § xv. and § xvii.—Celsus, De Medicina, 1. iv. cap. 2.— Aetius, 1. iv. cap. i. p. 99.—Tulpius, Observ. Med. 1. i. obs. 25.—Fab. Hildanus, cent. iii. obs. 17—19.—Forestus, Ob- serv. Chirurg. 1. iii. obs. 6.—Heister, In^t. Chirurg. p. 496. —Riverius, Observ. Commun. p. 406. et p. 676.—Bonet, Sepulchretum, 1. i. seel. xii. obs. 37., sect. xiii. obs. 1. kc, sect. xvi. obs. 9. 11.—Diemerbroeck, De Morb. Cap. et T .or. p. 219.—De la Motte, Tiaitf'- comp. de Chirurg. t. ii. p. 131. — Wt/./er, De Cap. Affect, obs. 49.—Littre, .\lt-m. de l'Acad. kc. de Paris, 1705, p. 70.—Friend, in Philos. Trans. No. 256.—Alberti, De Hydrocephalo. Halae, 1725.—Blan- card, Anat. Pract. c. i. obs. 48.—Kattschmid, De Hydroceph. Intemo mra; Magnitudinia. Jenae, 1752.—Morgagni, Dc Sed. et Caus. Morb. ep. xii. art. 1. 3. et seq.—Preysinrer, De Diagnosi Morb. Capitis. Vien. 1764.—Fothergill, Med. Observ. and Inquiries, vol. iv. 1771.—Klinkosch, Prog, de Hydroceph. rariori. Prag. M3.—Loftie, in Med. Observ. and Inquiries, vol. v. p. 121.—Watson, in Ibid. vol. iv. No. 6.25.— Aurivillius, De Hydroceph. Intemo 45 Annorum, in Sandifort's Thessur. vol. ii. No. 14.—Greding, in Ludwig Advers. Med. Pract. vol. ii. p. 469.—Ludwig, De Hydr Cerebri Puerorum. Lips. 1774.—Pohlius, De Hydroceph. Infantis rerens Nati interno et externo. Lips. 1777.—A. Dawson, Thought* on Hydroceph. Inter. Lond. 8vo. 1778. —Odier, Mem. de l'Acad. R. de Med. 1779, No. 13.—C. W. Quirt, De Hydrocep. Interno. Edin. 1779.; and Treatise on Dropsy ofthe Brain. Lond. 1791.—Rand, Med. Papers, kc vol. i. No. 7.—Pitschel, Anat. u. Chirurg. Aumerk. Dresd. 1784.—Sandifort. Excitat. Acad. t. ii. part i.; et in Mus. Anat. t. ii. p. 6.—Hooper, in Mem. of Med. Soc. of Lond. vol. i. No. 8.—Lettsom, in Ibid. vol. i.—Jameson, in Ibid. vol. iii. No. 13.—Cribb, in Ibid. vol. iv. p. 402.— Saxtorph, De Febre Hydrocephalica. Hafn. 1786.—Perci- val, Med. Facts and Observat. vol. i. p. 646.—Thom, Er- fahrungen, und Bemerk. p. 84.—K. F. Bader, Geschichte der Wassersucht der Gehirnhoehlen, oder des Schlagflussei der Kinder, 8vo. Frankf. 1794.—Lodemann, De Hvdr. Cer- ebri. Goet. 1792.—Flajani, Osservazioni Praticne sopra l'Idrocefalo, kc. Rom. 1791.—Hartmann, De Hydroce- phalo. Stuttg. 1794.—Meckel, De Hydrocep. Interno. Hal. 1793.—Rush, Med. Inquiries, vol. ii. No. 5. and 15—Leib, in Trans, of Phil. Soc. of Philad. vol. L part i. No. 2.— Cava/lini, Collezioni, kc. t. ii.—Blumenbuch, Biblioth. vol. iii. p. 616.—Buckholz, in Baldinger's N. Mag. b. i. p. 481., b. ii. p. 130.; Ibid. b. viii. p. 180.—Conradi, in Hufeland's Journ. der Pract. Arzneyk. b. vi. p. 453., b. vii. st. 2.—Fis- cher, in Ibid. b. i. p. 230.—A. Monro, Three Treatises on the Brain, the Eyes, and the Ear. Edin. 1797.—Thomann, Ann Wurceburg. kc. vol. ii. p. 64. 92. 104.—J. P. Frank, Acta Instit. Clin. Viln. ii. p. 451., iii. p. 44. ; et Cur. Horn. Morb. vol. vi. p. 161. 183. 197.—Duncan, in Edin. Med. Comment, vol. ii.—5. F. Simmons, in Ibid. vol. v. p. 415.— Percival, in Ibid. vol. v. p. 174.—Dobson, in Ibid. vol. vi. p. 219.—R. B. Remmett, in Ibid. p. 423.—Mackie, in Ibid. vol. vii. p. 21.—Willan, in Ibid. vol. vii. p. 330.—A. Hun- ter, in Ibid. vol. viii. p. 106.—.Eoson, in lb d. vol. viii. p. 325.—T. Aery, in Ibid. p. 332.—A. Campbell, in Ibid. vol. ix. p. 240.—Evans, in Ibid. vol. x. p. 299.—Dixon, in Ibid. p. 312.—W. L. Perkins, in Ibid. vol. xi. p. 198. ; Ca es of, vol. xiv. p. 401., vol. xix. p. 173.—Paterson, On Acute Hvdroceph. 8vo. Dubl. 1794.—Ackermann et Fischer, Klinischen Annalen von Jena, -t. i. p. 152.—Lanoix, Mem. de la Soc. Mtd. d'Emulation, t. i. p. 13.—Wiehmann, Ideen zur Diagnostik, th. iii. p. 43—117.—Baillie, Series of En- gravings, &c. fasc. x. pi. 3.—P. F. Hopfengartner, Unter suchungen iiber die Natur und Behandlung der Verschiede- nen Arten der Gehirnwassersucht. Stutt. 1802.—Hufeland, Bemerkung. iiber Blattern, &c. p. 476. et seq.—Kreysig, De Hydrocephali Inflammatorii Pathol. Viteb. 1B"0.—W. Row- ley, Treat, of the Dropsy of the Memb. of the Brain, and Watery Head of Children. Lond. 1801, 8vo.—Weaver, in Med. and Phys. Journ. vol. xv. p. 332.—Horsch, Annalen, h. i. p. 219.—Bard, in Journ. Gen. de Med. t. xxxii. p. 26. —Boupier, in Ibid. t. xxx. p. 377.—Collinet, in Ibid. t. xxxi. p. 157.—Jadelot, in Journ. de Med. Chirurg et Pharm. Paris, IbOe.—Spry, Med. aud Phys. Journ. vof. ii. p. 131.— C/utterbuck, in Ibid. vol. ii. p. 154.—C. Brown, in Ibid. vol. ii. p. 258. 327.—Ford, in Ibid. p. 261.—W. White, in Ibid. vol. iii. p. 113. 325. 358.—Shaw, in Ibid. vol. iii. p. 517.— Schmidt, in Ibid. vol. vi. p. G.—J. B. Davis, in Ibid. vol. viii. p. 98.—Garnett, in Ibid. vol. v. p. 121.—Bartlett, in Ibid. vol. \i. p. 401.—Patterson, in Ibi I. vol. xv. p. 119.— Coxe, in Ibid. vol. xviii. p. 213.—Fothergill, in Ibid. vol. xwii. p. 481.—Inquirer, in Edin. Med. and Surg. Journ. vol. ii. p. 52. 409.—G. G. Kuhn, in Ibid. vol. iii. p. 13.— j Clarke, in Ibid. vol. v. p. 261., vol. vi. p. 282., vol. xii. p. [ 105.—Male, in Ibid. vol. ix. p. 398.—Bate -nan, in Ibid. vol. xii. p. 119.—Salter, in Ibid. vol. xvi. p. 393.—Dickson, in Ibid. vol. xvi. p. 412.—Trail, in Ibid. vol. xvii. p. 237. (Analysis of fluid removed by tapping in chr. hydr.)—Li- | zars, in Ihid. vol. xvii. p. 243. 471. (On puncture in chr. hydroceph.)—Hood, in Ibid. vol. xvii. p. 510.—Thompson, in Ibid. vol. xviii. p. 46.—Afzelius, Hydr. Ventricuforum Cerebri Hist Morbi et Sectionibus Cadaverum illustratus. j Ups. 1804.—J. et C. Wenzel, Bemerkungen iiber die Hirn- i wassersucht, 4to. 1806.—Lange, De Hydr. Ventr. Cerebri. Erf. 1807.—Portenschlag-Ledermayer, Ueber den Wasser- kopf. Wien. 1812.—Wendelstatt, in Stark's N. Archiv. fiir die Geburtshulfe. b. ii. p. 711.—Autenrieth, Observ. de j Hydroce h. Acuto. Tub. 1811.—Formey, Von der Wasser- i sucht der Gehimhohlen. Berlin, 1810. ; et in Horn's Archiv, March, 18UI.— Hecker, Mag. fiir die Path. Anat. u. Phys. h. i.—Heinecken, in Hufeland u. Himly's Journ. d. Pr. DRUNKENNESS. 685 Heilk. Mars, 1811, p. 23.; DJid. 1812, p. 25.—Schdffer, in I Ibid. Sept. 1811.—Michaelis, in Ibid. Feb. 1812.—Tnom- son, in Lond. Med. Repos. vol. i. p. 16.—Cloquet, in Ibid. I vol. ix. p.410.—J. Cheyne, Essays on Hydrocep. Acutus, kc. I 2d. 8vo. Lond. 1819.—./. F. Coindet, Mem. sur l'Hydren ceph. ou Cephalite interne Hydrencephilique, 8vo. Gen. j 1818.—Cooke, in Trans, of Med.-Chirurg. Soc. vol. ii. p. 17. —Baron, in Ibid. vol. viii.—Vose, in Ibid. vol. ix. p. 354. (Paracentesis.)—J. C. Smith,Ou Hydrenceph. or Dropsy of the Brain 8vo. Lond. 1814.— Rasori, in Giorude della Soc. Med.-Chirurg. di Parma, vol. ii. No. 4.—L. A. Goelis, Ueber d. Vorziiglichsten Krankht. d. K ndl. Alters. 8vo. 1820—1824. Wien.; also on Hydr. Acutus, or Inflammato- ry Water in the Head, translated by R. Gooch, 8vo. Lond. 1821.—G. D. Yeats, Of the early Symptoms that lead to Water on the Brain, 2d ed. 8vo. Lond. 1823.— J. Cooke, Treatise on Nervous Diseases, kc. vol. i. p. 379.—Hufeland, in Nouv. Journ. de Med. t. xii. p. 42.— J. Crampton, in Trans, of Irish College of Phys. vol. i. p. 176.—J. B. Evan- son, in Ibid. vol. iv. p. 156.—Mills, in Ibid. vol. v. p. 350. —Itard, in Diet, des Scien. Mtd. t. xxii. p. 219.—Duncan, in Trans, of Med.-Chirurg. Soc. of Edin. vo'. i. p. 205.— Miller, in Ibid. vol. ii. p. 243.—Fallot, in Med.-Chirurg. Rev. vol. ii. p. 902.—Oppenheim, in Edin. Med. and Surg. Journ. vol. xxix. p. 358.—G. Blane, in Med. and Phys. Journ. Oct. 1821.—Hood, in Edin. Med. and Surg. Journ. Oct. 1821—Guersent et Breschet, in Dkt. de Med. t. xi. p. 3(10. 320.—Gardien, Tr. d'Accouchem. et des Mai. des Femmes el des Enfans, 3d ed. t. iv. p. 139.—Reynault, Med. and Phys. Journ.vol. xi. p. 539.—Girdlestone and Costerton, in Ibid. vol. xlvii. p. 183.—Ritter, Morbi Hydrocephali Historia, 8vo. Ber. 1824.—J. Abercrombie, Pract. Research- es on Dis. of the Brain and Spin. Chord, sect. vi. p. 130.; and Edin. Med. and Surg. Journ. vol. xiv. p. 292.—A. Du- ges, in Diet, de Mid. et Chir. Prat. t. x. p. 130.; et in Ephemerides Mid. de Montpellier, t. i. p. 292., t. ii. p. 132 —275.—Charpentier, in Med. and Surg. Journ. and Repos. vol iv. p. 36.; and Archives Gene>. de Med. t. sxi. p. 315. —Dance, in Arch. Gen. &c. t. xxi. p. 508., t. xxii. p. 295. —Lobenstein Label, Die Erkenntniss und Heilung der Ge- hirnentzundun», des itinera Wasserkopfes u. der Krampf- krankheiten im Kindlichen Alter. Leips. 1813.—D. A. G. Richter, Die Specielie Therapi ■, kc. b. iii. p. 158.—V. N. Ab. Hildenbrand, Institut. Practico-Medicae, t. iii. p. 88.— M ckel, in Hand, der Path. Anat. b. i. p. 260.—Bresch t, in Magendie's Journ de Physiol, vo1. i. p. 92.. vol. ii. p. 269., vol. iii. p. 241.—Burdach, Vom Leben und Bau des Gehirns, b. iii. p. 514.—J. L. Bracket, Sur l'Hydrocephalite, ou Hydr. Aigiie des Vent. duCerv 8vo. Paris, 1819.—Porter, in Med. Ch rurg. Journ. and Rev. No. iii.—W. Shearman, On the Nature, Cause*, and Treatment of Water in the Brain, 8vo. Lond. 1825.—Abercrombie, On Dis. ofthe Brain aud Spinal Chord, 8vo. p. 126. et seq.—Underwood, on Diseases of Ch Idren, ed. by Merriman, 8.o. Lond 1827, p. 357. note by editor.—A. Monro, Morbid Anatomy of the Brain, vol. i.; Hydrocephalus, 8vo. Edin. 1821.—Leu- rat, Sur les C iuses, la Naure, et le Traitement de l'Hydro- ceph. Aigiie, kc Lyont, 1828.—C. Himly and /.ang-enoecfc, in Comment. Soc. Reg. Scient. Got. Recent, vol. vi. Class. Phvs. p. 61. et 73. pi. 1—5.—J. Mackintosh, in Lancet, No'. 247. p. 237—266.—Conquest, in Ibid, for 1830, No. 0. —Greatwood, in Ibid. No. 299. p. 238.—Elliotson, in Med- ical Gazette, vol. xi. p. 405. 436.—Graefe, in his and Wal- ther's Journ. fur Chirurgie, 1831, b. xv. p. 3.—Trail, in Trans, of Proviu. Med. Associat. vol. i. 1833.— Craigie, in Edin. Med. and Surg. Journ. July, 1832. (An interesting case, with remarks.)—Russel, in Ibid. July, 1832, p. 43.— F. W. Oppenheim, in Rust's Mag. f. d. Gesammte Heilk. b. xxiv., reviewed in Edin. Med. and Surg. Journ. vol. xxix. p. 358., where arguments for and against puncture are adduced. DRUNKENNESS — Intoxication. — Syn. Temulentia, Pliny, Plater, &c. Paraphrosyne temulenta, Sauvages. Ebrietas, Lat. Ivresse, Fr. Trunkenheit, Rausch, Germ. Ebbro, Ital. Ebriety, Inebriation. Classif. HI. Class, I. Order (Author). 1. Defin. — Mental exdtement, followed by stupor or coma, from the excessive use of fer- mented or distilled liquors. 2. The frequent occurrence of intoxication. either casually or as a confirmed habit, would justify the notice I am about to take of it, even independently of its influence in causing and modifying disease. But it is chiefly to the more complete states of intoxication, and especially those demanding medical care, that attention will 58 be here directed. Drunkenness, in its various phases—from the daily indulgence in more vinous or spirituous fluids than is required, but short of effecting the nervous system in a very evident manner, up to that degree of excess by which the senses and intellects become obscured or entirely lost — predisposes to many diseases, and directly causes others. Slighter excesses in the use of fermented liquors — particularly wine and malt liquors—occasion plethora, with all the consequent ills, especially gout, apoplexy, paralysis, and congestion of the abdominal vis- cera. Greater excesses, and the too free use of spirits, exhaust nervous and vital power, in- ducing tremors, nervousness, delirium tremens, encephalitis, paralysis, and insanity; occasion affections of the digestive organs, particularly anorexia and dyspepsia, diarrhrjea and dysentery, inflammation, and structural changes of the biliary organs; and produce disorders of the urinary and sexual functions, even sterility and impotency; and ultimately, lesions of the kidneys, and dropsies. 3. Drunkenness is not a vice of recent date, although it may have become more common with the progress and diffusion of luxury. We find it mentioned in the early history of the Jews ; and Tacitus informs us that it was prevalent amongst the ancient Germans. It is tolerably evident, from the ancient lytic and dramatic poets and satirists, that it was by no means infrequent amongst the higher classes in Greece and Rome. Hippo- crates notices its worst states, both inhis-4pAor- isms and in his Prognostics: and it does not ap- pear to have been considered a very culpable sort of indulgence even by some ofthe sages of antiqui- ty. Plato cautions against allowing wine to youths at an earlier age than eighteen years, and against becoming intoxicated before forty; but, after this age, he considered some degree of in- dulgence in this way pardonable. This was pos- sibly, also, the opinion of Socrates. " Hoc quoquc virtutem quondam certamine, magnum Socratem p dmara promeruisse ferunt." Corn. Gall. Eleg. i. ver. 49. And Horace states, that Cato the Censor often warmed his virtues by wine. " Narratur et prisci Catonis Sspe mcro caluisse virtus." It is evident that the vice increased amongst the ancients with the diffusion of luxury; until, at last, even the ladies occasionally followed the example so generally set them. Valerius Ma xi mus (1. ii. cap. i.) states, that, in the earlier periods of Roman history, the women seldom drank; and Seneca (Epist. 95.) remarks, that, at a later period, they indulged so freely in this way, that they became nearly as subject to the diseases occasioned by the practice as the men. Erroneous opinions as to the effects of intoxication upon the frame seem to have been very early entertained, and were generally prevalent in the fifteenth and sixteenth centuries. Montaigne mentions, that the celebrated Sylvius informed him that an occasional debauch was beneficial, inasmuch as it roused the energies of the stomach; an opinion long entertained by medical men, but zealously combated by MM. Hommets and Langlois. There can be no doubt, however, that, as expressed by the late Dr. Gregory, an occasional excess is, upon the whole, less injurious to the constitution, than the practice of daily taking 686 DRUNKENNESS — Symptoms. a moderate quantity of any fermented liquor or spirit. 4. i. Causes.—This destructive habit, not many years ago but too prevalent even in the upper classes in the more northerly countries of Europe, fortunately now no longer exists, or not nearly to the same extent as before : but it is still as general as ever amongst the lowest orders, and those of weak constitutions, who have been in- dulged in youth, or uncontrolled, or accustomed at that age to taste cordials and spirituous liquors, or who possess little force of character or firmness of resolution. The unfortunate and unhappy, those of uncertain occupations, or whose homes are made miserable; also tavern-keepers, coach- men, commercial travellers, singers, working me- chanics, persons whose parents have been drunk- ards, and those who are idle and unoccupied, and frequent clubs or meetings of lodges, &c.; often have recourse to it. The weak, good-natured, and Bocial, not infrequently become addicted to it, from the manners and indulgences of those with whom they associate, until the want of the accustomed stimulus becomes distressing, and the resolution gives way before the desire of gratifying it, and thus the habit is confirmed. 5. ii. Symptoms.—A. The earlier phenomena of cbriety are, mental exhilaration, joyousness, dissipation of care, with talkativeness, flushed countenance, increased animation of the features, especially of the eyes; a more copious transpir- ation from the cutaneous and pulmonary surfaces, and secretion of urine; augmented thirst; and full, frequent, and strong pulse. If the intoxi- cating fluid be more largely partaken of, vertigo, tinnitus aurium, double vision, and unconnected trains of ideas, generally uncontrolled by the will, supervene. During slight intoxication, the prevailing disposition and pursuits are made mani- fest; and hence the saying, " In vino Veritas." The irritable and ill-tempered become quarrel- some; the weak and silly are boisterous with laughter and mirth, and profuse in offers of ser- vice; and the sad and hypochondriacal readily burst into tears, and dwell on mournful topics. In a more advanced state, the excitement ap- proaches nearly to that of delirium : the con- ceptions become disordered, the ideas confused, and various hallucinations sometimes are ob- served; the voice is thick; the eyes vacant; the face pale; the voluntary motions imperfect and unsteady; and the limbs tremulous, or incapable of their offices. Vomiting occasionally occurs in this state, and either diminishes or shortens the consecutive state of stupor. In a still more ad- vanced stage, all the phenomena about to be described sometimes occur — occasionally with convulsions, and signs of dangerous coma, or even of asphyxy. The phenomena of drunkenness are happily and briefly expressed by Lucretius:— ------" Cum vini penetravit — Consequilur gravitas membrorum, prxpediuntur Crura vacillanti, tardescit lingua, madet mens, Nant oculi; clamor, singultus, jurgia gliscunt." 6. B. The phenomena of deep Intoxication have been very closely and accurately studied by Dr. Og sto n ; whose opportunities of witnessing them, particularly in their more dangerous associations, and as following the use of ardent spirits, have been unusually great. I shall, therefore, follow, in great measure, the description he has given of them. It should be recollected that the effects of spirits or other intoxicating liquors on the frame will vary with the habits of the individual ; with his state of body, especially as respects vascular plethora; with the kind of inebriating ageut in- dulged in; and the existing condition of stomach, chiefly as respects the presence of alimentary matters. But the most powerful modifyiugugent Is temperature. Warmth increases the nervous and vascular excitement characterising the early stage; and diminishes the consequent exhaustion. Cold suppresses and shortens the early excitement, and hastens as well as augments the oppression and exhaustion of the advanced stage.— a. In the larger proportion of cases, however, after a longer or shorter period of unusual mental vigour, nerv- ous excitement, and increased action, varying according to the surrounding temperature, the brain becomes oppressed; the powers of volun- tary motion, which are early impaired, fail en- tirely; the mental manifestations are suspended; and, in the most severe cases, sensation is lost completely. In most instances, this state super- venes gradually; but sudden exposure to cold will often induce it rapidly. The person feels drowsy, and appears to fall into a sound sleep ; but it is discovered, when the attempt is made, that he cannot be aroused to consciousness by any effort, or, if it partially succeed, he is hardly sensible of surrounding objects, and immediately lapses into his former state; the limbs remaining in whatever position they may be placed. At this period the face is pale, with or without nausea; or it is flushed; the eyes are vacant and suffused, sometimes glazed; the pupils dilated, and con- tracting very imperfectly, or not at all, by ex- posure to light. The temperature of the head is generally above natural; but that of the extremi- ties, and often of the surface generally, is con- siderably lowered, or but little affected in the milder cases. The pulse, which was at first quick and excited, becomes feeble, small, and ultimately slow, and entirely wanting at the wrist, according to the degree of intoxication. Respir- ation is usually infrequent ; the separate acts of inspiration and expiration, particularly the former, occupying a very short time; and is wholly or chiefly abdominal. The breathing is often labo- rious in the most advanced states; and, in these, the inspirations are convulsive, the chest expand- ing by the rapid contractions of the associated muscles of respiration. Strabismus, or tetanic con- vulsions, or spasms of particular parts, sometimes supervene in the more advanced states, and are uufavourable signs. 7. b. Such is the more common state or form of drunkenness: but alcohol occasionally causes modified effects; and, without much previous ex- citement, but always with more or less mental disturbance, produces prostration of the functions ofthe brain; the intellects, volition, and sensation failing almost simultaneously. In these cases, the face is pale, the eyes are more or less lively or injected, the pupils contracted; the pulse fre- quent, full, and soft; the respiration laborious or stertorous; the temperature uniform, and either at or above the natural standard, but seldom below it. The circulation, respiration, and generation of animal heat, may go on for a con- siderable time, in these, notwithstanding the para- lysis ofthe brain; or continue until this organ has DRUNKENNESS —Pathology and Diagnosis. 687 recovered from its torpor, provided the body be not exposed to a cold atmosphere, or placed in unfavourable circumstances. 8. C. Appearances after death.— These very nearly resemble those produced by asphyxia. The countenance presents marks of anxiety or of convulsion; the eyes are prominent, the pupils dilated; the face livid or swollen; the lips blue; the cellular tissue injected with dark fluid blood; the air-passages reddened; the lungs dilated, and loaded with fluid dark blood, and more or less frothy mucus in the air-cells. The right cavities of the heart, the venae cavae, and the pulmonary artery, are filled with blood of a similar appear- ance. The left ventricle, aorta, and coronary veins, also contain a little dark blood; and the liver and kidneys are loaded with it. Blood pos- sessing the same characters also fills the sinuses, veins, and even the smaller vessels of the ence- phalon. The cerebral structure is generally firm- er than usual. More or less serum is found in the ventricles and between the membranes of the brain. Dr. Ogston confirms the testimony of Wepfer, Voight, Carlisle, and others, as to the effused fluid being impregnated with alcohol. In describing the appearances in one of his cases, he states, that about four ounces of fluid were found in the ventricles, having all the physical qua- lities of alcohol; as proved by the united testi- mony of two other medical men, who saw the body opened, and examined the fluid. He thinks that the effusion takes place previously to the coma of intoxication; as he found it in considerable quaiv tity, in two cases of drowning in the stage of violent excitement from spirits. Muller states, that he found air in the sinuses ofthe encephalon. The mucous coat of the stomach, particularly in habitual drunkards, is thickened and softened; this latter change sometimes existing throughout the whole extent ofthe small intestines. In rarer cases, the coats of the stomach are remarkably thickened and hardened. Injection, and some- times ulceration, of the small intestines, are also met with. The liver is frequently mottled, en- larged, and otherwise diseased. The kidneys are often enlarged, softened, paler than usual, gra- nulated, &c. : the urinary bladder greatly en- larged and thickened. 9. iii Pathology.— That a portion of the alcoholic constituent of the intoxicating fluid is absorbed and carried into the circulation, is proved by the odour of the expired air, and by the phy- sical properties of the fluid effused within the head of persons who have died soon after having taken spirits to excess; and it is probable, if the urine were analysed, that a considerable quantity would be found to have passed off in this excre- tion. Deep intoxication seems to be occasioned as follows :— During the general nervous and vas- cular excitement consequent on the stimulus, in- creased determination to the head takes place, attended by excited vascular action; which soon terminates in congestion, as the excitement be- comes exhausted, and gives rise to drowsiness, sopor, or coma. With this state of disorder, effusion of serum takes place in the ventricles and between the membranes, heightening the sopor and coma. When the congestion or effusion amounts so high as to impede the functions ofthe organs at the base of the encephalon, and of the respiratory nerves, respiration becomes infrequent and laborious; and, consequently, the changes produced by it on the blood insufficiently per- formed. In proportion as the blood is less per- fectly changed in the lungs, the circulation through them is retarded, and the phenomena of asphyxy — congestion of the lungs, right side of the heart, brain, and liver; the circulation of the unarterialised blood; the imperfect evolution of animal heat, and sedative effects upon the brain and nervous system generally — follow in a more or less marked degree, according to the quantity of intoxicating fluid which has been taken; and either gradually disappear after some time, or in- crease until life is extinguished. These pheno- mena are heightened by cold, which depresses the vital actions ,in the extremities and surface to which it is applied, and increases the congestion of the above organs. The fatal consequence of intoxication is often averted by the occurrence of vomiting; the stomach thereby relieving itself from a great part of the poison; and the person recovering, after some hours of the above state of comatose intoxication. If the intoxicating fluid has been thrown or drawn off soon after its inges- tion, the recovery of consciousness is more imme- diate. When intoxicating liquors are taken fre- quently, and to an amount short of intoxication, the digestive canal and liver are the first to suffer :— first in their functions, and subsequently in their circulation and organisation; this being one ofthe most fruitful sources of all the diseases, functional and organic, of these viscera, as well as of the nervous and vascular systems. 10. iv. The Diagnosis of intoxication is not always easy. It is difficult to distinguish it, io its more profound states, from—(a) apoplexy, or concussion ofthe brain; (b) asphyxy; and (c) the extreme effects of cold. The odour of the breath is one of the best means of diagnosis; but is not to be depended upon alone: for a person may be apoplectic, asphyxied, or exposed to severe cold, after having taken only a small quantity of spirits; and apoplexy, asphyxy, and the effects of cold, often come in aid of the intox- icating agent, and heighten its effects: apoplexy, in those of a plethoric habit; asphyxy, from po- sitions interrupting respiration, in addition to the operation of the poison as above explained; and cold, in the manner already mentioned. It will be very difficult to distinguish those cases of in- toxication, where stertorous breathing is present, from apoplexy, unless by the smell ofthe breath, and ofthe matters thrown off the stomach. (See Apoplexy, § 67.) It will readily be distin- guished from syncope, by the laborious, infrequent breathing, by the smell of the breath, by the suf- fused eyes, and the livid or tumid features. 11. v. The Prognosis is unfavourable, when the pulse is indistinct, or nearly gone from the wrist; when the respiration is laborious, ster- torous, or puffing; when the countenance is pale, or livid and tumid; the pupils either much dilated or much contracted; the coma profound, and the extremities cold. Strabismus and tetanic spasms are also very dangerous symptoms; the former having been observed in three out of four fatal cases recorded by Dr. Ogston. When these symptoms do not appear, the ill effects pass off, in a great measure, within twenty-four hours, although it is often much longer before all the functions regain their healthy tone. 688 DRUNKENNESS —Treatment. 12.v1.Treatment.— A. Of deep Intoxication. — a. The propriety of immediately removing the intoxicating liquor from the stomach cannot be disputed. This ought to be instantly done by the stomach-pump; for, in extreme cases, the stomach has become too torpid to be readily acted on by emetics. Mr. Macnish advises the fauces to be tickled, and the sulphate of copper, or the sulph. of zinc, to be used as an emetic. Pressure on the epigastrium, when this organ is full, will insure the effect of emetics, when the pump is not at hand. When the stomach is not distended, the introduc- tion of warm water will be often necessary before its contents can be withdrawn by this instrument; and, when it contains much solid food, the same measure will be requisite; the distension thus produced, often of itself causing the reaction of the organ, which may be assisted by pressure on the epigastrium. Sometimes the glairy state of the contents will render their removal by the tube somewhat difficult; but this may also be over- come by dilution, and the mechanical means now noticed. When the temperature of the head is high, or not below natural, and that of the sur- face generally not greatly reduced, the affusion of cold water on the head is both a safe and effi- cacious remedy. 13. b. I agree with Dr. Darwin, Dr. Trotter, Mr. Macnish, and Dr. Ogston, in reprobating indiscriminate bleeding in deep intoxication. Cases which seemed urgently to require it, were injured by it in the practice of this last physician. Dr.DAR- win remarks, that, when drunkenness " is atten- ded with an apoplectic stupor, the pulse is gener- ally low; and venisection has sometimes destroyed those who would otherwise have recovered in a few hours." The antidotes most to be relied upon are the preparations of ammonia (Masurer, Broom ley, Macnish, and Ogston),particular- ly the carbonate and liquor ammonia acetatis, and cold or tepid affusion on the head. M. Gerard prescribes the liquor ammonia, in repeated doses of seven or eight drops. Vinegar has little effect; and it, as well as other acids, are considered inju- ious by Al b e rti. Coffee and green tea are much more efficacious; and have been very generally recommended. Alberti advises the application of camphorated spirit to the crown of the head. 14. c. When the temperature of the surface is at all reduced, means should be used to raise it. In many cases, the removal ofthe contents ofthe stomach, and the preservation of the natural tem- perature, with elevation of the head and a proper position of the body, all ligatures being removed from it, are the only measures required. In the more profound states of intoxication, however, external warmth to the extremities and epi- gastrium must not be dispensed with. It should always be kept in recollection, that a degree of cold which would not be injurious in other cir- cumstances, may prove fatal to a person in this condition. As long as coma continues, the pa- tient should not be left, lest be get into a position that may induce asphyxy. When violent deli- rium follows drunkenness, the shower bath, or cold affusion, and afterwards the exhibition and frequent repetition of tartar emetic, will often calm the patient. 15. d. The removal ofthe distressing symptoms consequent upon intoxication is sometimes a mat- ter of medical duty. The principle contended for by the celebrated Brown, and but too uniformly practised by him, of keeping up the excitement, was inculcated, and no doubt followed, by the monks of the Schola Salernitana; they, good souls, recommending — '■ Si nocturna tibi noceat potatio vini, Hoc tu mane bibes iterum, et fuerit medicina." If there be no sickness, black and green tea, mixed, may be taken, as advised by Alberti; but where nausea exists, soda water, spruce beer, Seidlitz powders, the citrate of ammonia in a state of effervescence, and any neutral aperient salt in effervescing and aromatic draughts, will speedily remove disorder. Afterwards, moderate doses of sulphate of magnesia in compound infu- sion of roses, with a little additional sulphuric acid, will restore the digestive functions. If diarrhoea exist, the liquor ammonia? acetatis, and spirit. ammonias aromat., with infusum calumbee, and tinct. camphorae comp., will soon remove dis- order. When headach is distressing, and the skin hot and dry, the shower bath, cold sponging the head, saline aperients in an effervescing state, and tea, are, upon the whole, the safest means. Tonics, in conjunction with purgatives, may also be taken. 16. B. Prophylactic means. — a. The propen- sity to drunkenness, or even to that degree of excess which falls far short of intoxication, is seldom or ever removed when once established. In early life, and when the evil begins to mani- fest itself, the possibility of checking it may be indulged; but even then it is a difficult matter to succeed. Success will mainly depend upon the constitution and character of the individual, and the society he is allowed to keep. But instances have occurred, where there appeared to have been a growing addiction to it, of the evil having been arrested, by tartar emetic and other nauseous matters having been given to persons in a state of intoxication, or soon afterwards. I have, in seve- ral cases, advised some tartar emetic to be put into a glass in which soda water was about to be taken, in order to remove the disorder and sickness oc- casioned by extraordinary excess. The distress- ing sickness thus induced, and which may, in the helpless state of such persons, easily be pro- longed, has occasioned such disgust at, and dread of, all intoxicating beverages, as to cause them to be shunned for a long time afterwards. But this plan, or even repetitions of it, will generally fail with those who have become habituated to this species of indulgence: particularly those who drink spirits, and who resort to it before dinner, and when unallured by conviviality: these are either altogether irreclaimable, or to be reclaimed only by careful management, and a very gradual diminution of the daily quantity of the intoxicating agent. The use of sulphuric acid in tonic infusions is sometimes of service in such cases as are check- ed at their commencement, the mind being active- ly and agreeably occupied. But medical means cannot be much relied upon, unless in conjunction with a judiciously managed moral restraint 17. 6. It may be gathered from Plutarch, Pliny, and others, that various substances were sometimes taken by the ancients, with a view of counteracting the intoxicating effects of wine. Some of these were both disgusting and ridiculous enough. Others, as olives and olive oil, absinthium, crocus, and resinous purgatives, were, perhaps, not alto- gether destitute of some influence. The Greeks DUODENUM — Functional Disorders of — Pathology. 689 are said to have used common salt for this pur- pose; and the Romans surrounded their heads by wreaths, formed of various refreshing plants. Nothing further, however, may be said on this topic, than that intoxication, and perhaps various consecutive ill effects, will not so readily be pro- duced when wine is taken upon a very large meal; but if this become a habit, it will very speedily induce gout or apoplexy. Cold applica- tions, or cold sponging the head, will also delay or prevent intoxication, unless excess be carried to a worse than beastly length. Bibliog. axd Refer.—Hippocrates, Aph. v. 5.; De Morb. ii. xxii. 2—4.; Predict, ii. 24—26 —Horace, Ode 21. 1. iii. v. 11.—Lucretius, 1. iii. v. 475.—Stromer, Decreta Medica de Ebrietate. Lips. 1531.—Willich, Problem, de Ebriar. Affect, et Morib. Fr. 1543.—Montaigne, Essais, 1. ii. cap. 2.—Magiras, De Vinolentia ejusque Malis. Fr. 1618. —Hommets, Nom ergo singulis Mensibus semel repetita Ebrietas salubris. Paris, 1643.—Langlois, Non ergo unquam Ebrietas salubris. Paris, 1665.—Rolflnck, De Ebrietate et Crapula. Jen. 1667.—Wepfer, Observ. p. 7.—Waldschmidt, De Ebrietate < t insolentibus aliquot ejus Affectibus. Geess. 1677.—Ettmuller, De Temulentia. Lips. 1673.— Hanne- mann, De Usu et Abusu Iuebriantium. Kiel, 1679.—Rust, Ebrietas medice* considerata. Reg. 1682.—Alberti, Therapia Medica. Halae, 1721, 4to. p. 1033.; et De Ebrietate Foemi- narum. Hala>, 1737.—Cartheuser, De Noxa et Utilitate Ebri- etatis. Fr. 1740.—Darwin, Zoonomia, vol. iii. p. 497.— Plainer, De Ebriositate. Lips. 1799.—Trotter, Essay,Med. Philosoph. and Chemical, on Drunkenness, and its Effects on the Body, 8vo. Lond. 1804.—Voight, Mag. fur den Neuest. Zustand der Nat. b. iii. p. 326.—Gerard, Med and Phy. Journ. Aug. 1821.—R. Macnish, Anatomy of Drunk- enness, 3d ed. 12mo. 1829.—F. Ogston, On the mo e ad- vanced Stages of Intoxication. Edin. Med. and Surg. Journ. vol. xl. p. 276.—J. Frank, Praxeos Med. Univ. Praecepta, vol. i. pars ii. sect. i. p. 671. DUODENUM —Its Diseases. —1. That the duodenum performs an important part in vari- ous diseases, and that it is itself the chief seat of serious ailments, which are with great difficulty, or not at all, distinguishable from disorders of the stomach, pancreas, gall-ducts, liver, or right arch of the colon, cannot be doubted. Some writers, especially Dr. Yeats, Broussais, and his fol- lowers, suppose that affections of this viscus may be ascertained by attentive observation. They may in some cases; but with no degree of cer- tainty; for, after the most diligent investigation of a train of phenomena apparently emanating from this organ, the inferences we shall arrive at will often possess only a certain degree of proba- bility; for the same, or very similar symptoms, may proceed from the other viscera now named. It must, however, be admitted, that serious disorder of the duodenum will seldom exist without the functions of these organs beiug more or less dis- ordered, as well as those ofthe stomach and small intestines; and ultimately organic change may be propagated to a greater or less extent from this viscus to one or more of them. It becomes, therefore, a matter of great importance to be ac- quainted with the symptoms occasioned by the more common pathological conditions of the duo- denum, although we are at the same time con- vinced that these symptoms may be produced by changes in some one or more of the immediately adjoining organs. With all this uncertainty, how- ever, the experienced observer will often come to just conclusions as to the seat and nature of the dis- ease, founded on his knowledge of the functions and morbid relations of this and the surrounding parts. The duodenum is liable to all the functional and organic changes described in the article Di- gestive Canal; but in different relative degrees of frequency 58* I. Functional Disorder of the Duodenum Classif. —I. Class, I. Order (Author). 2. i. Patholooy.—(a) It is extremely probable that impaired function of this viscus gives rise to various symptoms of indigestion; warranting the designation of duodenal dyspepsia, if they could be distinguished from those proceeding from the stomach. But, granting that they can, we have no proof that the duodenum is the sole, or the chief seat of disorder, even in those cases which seem to admit of the least degree of doubt of such being the case. For, owing to the intimate struc- tural connection — by continuity of tissues, blood- vessels and nerves — even functional disorder can- not exist to any sensible amount in it without being extended to the stomach, intestines,pancreas, and biliary organs. Asthenia, or deficient vital action ofthe duodenum, may be inferred in cases characterised by an unimpaired, irregular, or ra- venous appetite; by constipation, and a deficient secretion and excretion of bile, the stools being light coloured, greyish, or foetid; by a loaded se- dimentous urine; by a feeling of languor and drowsiness, with fulness at the right epigastrium, and oppression and sense of distension towards the right hypochondrium, or right shoulder-blade or loin, two or three hours after a full meal; occa- sionally by headach or vertigo; by absence of fever, and a pale, or foul lurid appearance of the cutaneous surface. But, in this state of disorder, the collatitious parts are coetaneously, and some of them even co-ordinately, affected. In attempt- ing a fine series of pathological analysis, let us not be carried away either by flights of imagination or by efforts at mathematical precision, and attribute to a single organ what proceeds from several. But let us merely endeavour to interpret the pheno- mena of nature aright, according as they actually exist, and not as we suppose, or would have them to be. (See Indigestion.) 3. (b) Accumulations of sordes, the presence of add and acrid matters, of worms, or of morbid bile, may very probably take place in the duode- num as a consequence of indigestion, or atony of the stomach, or of torpor ofthe liver, or even of the preceding affection; may irritate more or less its mucous surface; and, from its nervous and other structural connections, disorder the functions of digestion, chylification, assimilation, and faecation; but the ensemble of symptoms that result can seldom be distinguished from those proceeding from disease of the stomach, pancreas, and biliary organs, owing to the reasons already assigned. These reasons will also explain the fact, that irritations seated primarily in this part may be propagated, along the digestive tube, to the stomach on the one hand, and to the intes- tines on the other; and along the ducts, to the liver and gall-bladder on the one side, and to the paucreas on the other: and I believe further, that frequent repetitions of such irritations, occa- sioned either by the nature of the ingesta, or by the state ofthe secretions poured into it, may take place without this viscus suffering materially in structure; and yet the disorder propagated" from it to its collatitious organs may terminate in struc- tural change of them. Such results are most likely to supervene in those who partake of a highly seasoned and stimulating diet; who in- dulge in vinous or spirituous liquors, or take too much or imprpper food. Irritation of the duo- 690 DUODENUM — Inflammation of—Pathology. denum very probably constitutes a part of certain forms of dyspepsia; and even pyrosis, and other ailments frequently imputed to the stomach and the biliary apparatus may, with equal justice, be referred to this viscus; but it cannot be said to be the only part in fault, or even that primarily disordered; for it may be affected simultaneously with its related organs by changes primarily im- plicating its nerves and circulation. 4. ii. Treatment.— But little need be here added to what is advanced on this topic in the article Indigestion. It is obviously of import- ance to promote the functions of the duodenum by those means which are the best calculated to procure a due secretion of bile; as this fluid is essentially requisite both to the performance of those functions, and to the preservation of the tissues of the viscus in their healthy condition. But at the same time accumulations of faecal or morbid matters in the bowels should be removed. A full dose of blue pill, or of hydrargyrum cum creta, should be given at bedtime with the common purgative extracts, and in the morning any ofthe aperient medicines in the Appendix, particularly F. 266. 382. 872. Dr. Yeats recommends either the infusion of chamomile flowers with the wine of aloes and liquor potassae, or an infusion of quassia and senna with sulphate of potass, taken morning and mid-day. These, orF. 506. 547. 562., will be appropriate in most cases. But in those in which irritation is presumed to exist, I have preferred the following, which may be given daily, or on alter- nate davs, until the evacuations become natural. No. 196. R Pilul. Hydrarg. gr. iij.; Pulv. Ipecacuanha; gr. ss.—j.; Extr. Colocynth. Comp.; Extr. Hyoscyami, aa gr. ij.; Saponis Duri gr. j. M. Fiant Pilulae duas hora, somni sumenda?. No. 197. R Soda Sub-carbon, gr. xij. ; Extr. Taraxaci £j. ; Infus. Calumba; et Infus. Senna' Comp. aa Jss.; Spirit. Ammon. Arom. ^ss.; Tinct. Cardam. Comp. £j. M. Fiat Haustus primo mane capiendus. 5. When these fail of fully evacuating the bowels, the stools still continuing unnatural, or devoid of healthy bile, it will be advantageous to exhibit a full dose of calomel at bed-time, with the extracts of colocynth and hyoscyamus, and a grain of ipecacuanha; and a draught with the compound infusions of gentian and senna, with some neutral salt, in the morning. Having eva- cuated morbid matters, it will be requisite to give tone to the digestive organs, and to preserve a healthy secretion of bile, by prescribing two or three grains of hydrargyrum cum creta, or one or two of blue pill, at night, with extract of tarax- acum, or with soap; and the infusion of columba or any other tonic, or the decoction of sarsaparilla with taraxacum, in the course of the day. When the mercurial is relinquished, small doses of the nitro-muriatic acids, with the spiritus aetheris nitrici, or the chloric aether, may be taken in the infusion of cinchona. A course of Carlsbad, or of any other alterative and aperient waters, either alone or assisted by the above alterative pill, particularly when the biliary secretion continues disordered, will often be adopted with advantage. 6. As much benefit will often accrue from a well-ordered diet and regimen, as from medicine in this complaint. The patient should be careful to partake only of light food, in moderate quan- tity, and at regular hours. He should masticate slowly and perfectly, avoid malt and spirituous liquors, and partake sparingly of wine. He ought to establish regular and habitual evacuations of the bowels, and take active exercise in the open air. Horse exercise, and the energetic employ- ment of the muscles of the trunk and upper ex- tremities, are preferable to walking. The shower- bath, or cold plunge bath, followed by frictions ofthe surface, will also prove of great service. II. Inflammations of the Duodenum, and their Results. Classif.—III. Class,I.ORDER(^ufAor). 7. i. Inflammatory Irritation of the Duodenum. (a) The uneasiness or sense of fulness and weight which sometimes follows a meal in the course of two, three, or four hours, occasionally with a deep- seated, dull pain, or feeling of distention in the right hypochondrium, and extending to the right epi- gastrium, and backwards to the right shoulder- blade, may depend upon chronic or sub-acute inflammatory irritation or action in the duo- denum; and, if nausea or vomiting, or pain on firm pressure directed towards the situation of the intestine, accompany these symptoms, the lat- ter state very probably exists, either as a primary affection, or as a consequence of the disorders already noticed, and of affections propagated from the stomach or adjoining organs. The above in- ference will be further confirmed, if the tongue be loaded or furred at its root, its edges and point being red, and the papilla? erect; if the appetite be unimpaired, or even sometimes raven- ous; if the palms of the hands and soles be hot, and the countenance and cutaneous surface more or less unhealthy; and the bowels relaxed, griped, and the stools crude or offensive. Chronic In- flammation of the duodenum, especially affecting its mucous surface, is generally associated with disorder of the stomach, biliary organs, and intes- tines; and often with chronic eruptions of the skin, particularly herpes, psoriasis, pityriasis, and acne. The bov/els are in these cases usually irritated or irregular, the evacuations offensive and otherwise disordered, very rarely natural, oc- casionally containing much unhealthy bile, or evincing a deficiency or obstruction of this secre- tion. The skin is dry or harsh. There are also frequently slight fever, sometimes with chilliness, increased thirst, a gnawing sensation at stomach, or cravings for food, and variable capricious ap- petite. The spirits are often dejected, and occa- sionally disturbed by hypochondriacal or fanciful feelings. This state of disorder is not infrequent in females, and is in them often complicated with scanty, painful, and difficult menstruation, espe- cially in unmarried females; and with headaches and various nervous complaints. ( See Indiges- tion—Irritative and Inflammatory States of.) 8. (6) It has been supposed that cholera and bilious diarrhaa are chiefly owing to the acute inflammatory irritation of the internal surface of the duodenum by the morbid secretions poured into it; and doubtless such is the case in a great measure. But it should not be overlooked, that the organic nerves supplying the digestive tube are morbidly impressed at the same time by these secretions, and that the same agents quickly affect, by their presence, the whole canal, although the impression is more directly and powerfully made upon the mucous surface and nerves of this part In cholera, and certain kinds of poisoning, there- fore, where the internal coats ofthe stomach are violently irritated, the consequent phenomena are not to be imputed altogether, or even chiefly, to DUODENUM — Acute Inflammation of—Symptoms. 691 this circumstance; but in a great measure, and sometimes chiefly, to the change produced in the nerves of the organ, and propagated throughout the system to which they belong, as well as to the parts which they directly or indirectly influence. 9. ii. Acute Inflammation of the Duodenum.— Duodenitis (Duodenite, Fr.) may be inferred with much probability, but with no certainty; for acute disease of the liver and of the gall ducts, or of the pancreas or of the pylorus, will give rise to very nearly the same phenomena. I believe that acute inflammation is not frequent in this viscus, or, if it be, that it does not so often give rise to disorganisation, as in other parts of the digestive canal. There can be no doubt that acute, sub- acute, and chronic inflammations are sometimes propagated to it from the stomach on the one side, and from the intestines on the other, as well as from other adjoining parts; and it would appear, from cases which I have examined, and from some recorded by M. Andral (Archives Gen. de Mid. t. vi. p. 161.; and Clinique Medicale, t. iv. p. 344.), that inflammation may commence in the mucous surface of the duodenum, extend along the ducts, giving rise to obstructions of their canals, either with or without jaundice, and even advance to the organs to which they belong. We more frequently, however, meet with the conse- quences of inflammations of these parts, in post mortem examinations, than with the early inflam- matory appearances themselves; whilst some of the associated lesions admit of doubts being enter- tained whether they be the results of inflamma- tions, or of some other state of action; but that inflammation, in one or other of its forms, often attends these alterations, cannot be denied. Thus we occasionally observe thickening and injection ofthe mucous and submucous coats of this viscus, with obliteration ofthe common ducts, and these alterations with lesions of the biliary organs, a scirrhous or enlarged state of the pancreas, or ad- hesions of this last with the duodenum, or of the duodenum to other adjoining parts. Scirrhus of the pylorus not infrequently extends a con- siderable way along this intestine; and enlarge- ments of its mucous glands, or ulcerations, to which it is less liable than almost any part of the digestive canal, are also observed in some in- stances in the parts more nearly adjoining it; but we very rarely meet with a case presenting evi- dence of acute inflammation, and its undoubted results, upon dissection, confined altogether to the duodenum. 10. Symptoms.— a. Duodenitis, in any of its forms, is, therefore, very seldom limited, unless at its commencement, to this viscus; and, owing to the varied connections of this part of the canal, it may implicate more than one part of very differ- ent structures and functions. It may originate in any of the functional disorders already noticed; or may directly proceed from the kind and quan- tity of the ingesta, whether food, drink, medi- cines, or poisons; or from the irritating effects of the secretions poured into it from the liver or pancreas. Admitting, with Broussais, Andral, Boisseau, Abercrombie, Rostan, and oth- ers, the difficulty of recognising the disease during life, the existence of a dull, deep-seated, and draging pain, in a direction from the epigastrium to the right hypochondrium, right shoulder-blade, and loin, increased upon pressure made on these regions, or upon torsion of the spine; sometimes but little felt, excepting in these circumstances, and two or three hours after a meal, when it oc- casionally becomes severe, and is attended or fol- lowed by sickness or vomiting; a sense of heat, or of gnawing, or of a foreign body in the region of the duodenum; great thirst; unimpaired or even a ravenous appetite; and an irregular or relaxed state of the bowels, the evacuations being copious, crude, unnatural, and offensive, are strong evi- dences of inflammatory action in the duodenum, especially when attended by febrile commotion of the system, similar to that already described (§7.), and by emaciation : but, in such cases, the imme- diately collatitious organs may also be diseased. Even in the more severe states of inflammation of | this viscus, the pain and sickness may be very urgent a few hours after a meal, and yet but little complained of at other times, as in the rare case related by Dr. Irvine, where the duodenum only was inflamed and extensively ulcerated. | 11. b. More frequently, acute duodenitis is con- sequent upon gastritis; or complicated either with it, or with a similar change in the jejunum and ilium, or with both. When it has arisen from the extension of inflammation from the inferior surface of the liver, or biliary apparatus, or when this latter proceeds from it, the stomach generally participates in the disorder, at least of function. When an irritative or inflammatory state of action extends from the inflamed duodenum to the liver, I the pain rises often high in the right hypochon- i drium, sometimes to the right side of the thorax, especially after a meal; and is attended by bilious i vomiting, occasionally with bilious stools or diar- rhoea, followed by constipation, nidorous eruct- ations, prolonged digestion, a bitter taste in the i mouth, a yellow coated tongue, and a slight yel- lowness of the conjunctiva, and unhealthy or yellow appearance of the skin. (See Jaundice.) 12. c. The consequences of inflammatory action in the mucous surface ofthe duodenum are, its ex- tension — 1st, to the stomach or small intestines, or to both; and, 2d, to the ducts, occasioning, first, obstruction or obliteration of them; and, ultimately, congestion, engorgement, enlargement, or various other lesions either of the liver or of the pancreas, or of both, with jaundice, and other contingent changes. When the inflammatory action attacks the whole thickness of the parietes of the intestine, whether originating in its mucous coat, or extended to its more exterior tunics from collatitious parts, the pancreas, pylorus, duo- denum, ducts, and even the liver and colon, not infrequently become accreted or welded into one mass; in which the pancreas is often remarkably enlarged, hardened, or scirrhous, the ducts obli- terated or obstructed, and the accreted serous surfaces and cellular tissue hypertrophied, or in- durated, or granulated and tuberculated. A case of this description, of which I kept notes at the time, occurred in a dispensary patient, in 1820; since when, I have met with several others — two of them with Mr. Painter and Mr. Byam. In three cases of this description, recorded by Dr. Bright, and in one by Mr. Lloyd, fatty matters were voided in the stools; but this phe- nomenon either did not exist, or was overlooked in those which occurred in my practice. The instances adduced by Dr. Bright presented ulceration of the duodenum, which this able 692 DUODENUM — Acute Inflammation of— Treatment. . physician considered of a malignant kind; the] pancreas presenting the same diseased appearances as in the cases observed by me. 13. d. Thickening is one of the most frequent lesions to which the coats of the duodenum are liable; and occurs often in connection with a similar or more remarkable change in the py- lorus. Softening of the interior tunics is equally if not more common. Gangrene is very rare; as also are thinning or atrophy of the coats, ulcer- ation, and erosion or destruction of the villous membrane. Although enlargement of the mu- cous glands is more common in the duodenum than in the stomach, yet ulceration is, according to M. Boisseau, ten times more frequent in the latter than in the former. 14. e. In the cases oi ulceration ofthe duode- num on record, most ofthe symptoms accompany- ing chronic inflammation (§ 7.) were present, with diarrhoea; and, in Dr. Bright's cases, a dis- charge of fatty matters from the bowels. In M. C. Broussais's case, fatal haemorrhage took place into the intestinal canal, owing to the exten- sion of the ulcer to the coats of a large artery. In a case detailed by Dr. Hastings, the patient had complained, for two months, of occasional vomit- ing and costiveness; with pain and tenderness, on pressure, in the epigastrium and right hypochon- drium, below the margins of the right ribs, and extending to between the shoulders. The pulse was ninety-six, the countenance anxious, and the skin yellow; and the body much emaciated. The liver and stomach were healthy. In the duodenum, beyond the part into which the ducts entered, a cancerous ulcer was found, larger than a crown- piece, with ragged and everted edges. Its surface was irregular from fungous excrescences. The coats of the intestine, around the ulcer, were much thickened. The rest of the bowels were natural. 15./. Perforation ofthe duodenum may occur from ulceration, and give rise either to fatal peri- tonitis, as in the cases adduced by Dr. Aber- crombie and M. Roberts, or to adhesions and communications with other viscera; but these occurrences are rare. A case has been described by Dr. Streeten, in which a communication took place between this viscus and an external opening between the seventh and eighth ribs, through which articles of food and drink were frequently discharged. The duodenum was found much contracted beyond the perforation in it, which communicated by a canal, two inches and a half in length, through thickened cellular tissue to the external aperture. This lesion was com- plicated with extensive disease of the liver and thoracic viscera. The most common changes con- sequent upon inflammatory action in this viscus, are, jaundice, and adhesions to the adjoining parts (§ 12.); its coats becoming thickened, hardened, and otherwise changed; the morbid mass forming a tumour, which sometimes may be recognised towards the right ofthe epigastrium, near the end of the eighth rib, upon a careful examination. 16. iii. Treatment.— A. In the slighter forms of duodenitis, local depletions by cupping or leeches will frequently suffice; but when they are associated with manifest plethora and conges- tion of the portal circulation, a moderate bleeding from the arm will be preferable, in the first instance. A blister, or rubefacient plaster, ap- plied over the epigastrium and hypochondrium, after depletions have been carried sufficiently far, will act beneficially on the seat of disease, and will favour the secretion and excretion of bile. A full dose of calomel may also be given, and be followed either by a moderate dose of castor oil, or by a purgative enema. The effect of calomel upon the upper part of the alimentary canal is satisfac- torily shown, both by direct experiment and thera- peutical observations, to be.sedative of inflam- matory action in that situation. As the bowels are generally freely open in this disease, the object will be rather to correct than to increase the secretions from them. With this view, small or moderate doses of hydrargyrum cum creta, with pulv. ipecacuanhae comp., or pulv. Jacobi, may be given at night; and the nitrate of potash, with subcarbouate of soda in the infusion lini comp., or decoctum althoeae comp., with either extractum humuli or extr. taraxaci, according to the state of the bowels, during the day. After the alterative pills have been con- tinued a few nights, a teaspoonful each of fresh castor oil and olive oil may be taken on the sur- face of some aromatic water; and, if the stomach does not nauseate it, this dose may be repeated at bedtime, or in the morning, for some days. If the biliary secretion be not improved after a few days, a full dose of calomel should be given again, and the milder preparations continued in small doses for some time, and conjoined with ipecacu- anha, extract of hop, or hyoscyamus, or taraxa- cum, according to the state ofthe bowels. Where the bowels are very irritable, and the secretions morbid, the mercurials may, at first, be given with the extract of lettuce, or opiates, or Dover's powder; laxatives being subsequently resorted to for the removal of morbid collections. 17. B. In the more acute states of inflammation, one or more of the allied organs are often impli- cated, and both general and local bleedings, blisters, and other counter-irritants, and a full dose of calomel, or of calomel and opium, are requisite; after which purgative and emollient enemata may be thrown up, and gentle and cooling laxatives be given internally with anodynes, demulcents, and diaphoretics. If fe- ver, or a sense of heat, be felt, the nitrate of potash may be given, with the subcarbonate of soda and the sweet spirits of nitre, in camphor mixture, to which either the extract of taraxacum, or of hop, or of lettuce, may be added, according to the state of the bowels; the mild mercurial alterative being taken at bedtime. Afterwards the solution of acetate of ammonia and camphor mixture, with the wine of ipecacuanha, and tinc- ture of henbane, in small doses, may be resorted to through the day. If diarrhcea prevail, or su- pervene, the hydrargyrum cum creta should be given twice or thrice in the twenty-four hours, with small doses of rhubarb, or of compound ipecacuanha powder, in the form of pill; with small doses of magnesia in the compound infusion of orange-peel, or in any aromatic water. If cos- tiveness occur, a full dose of calomel, with rhu- barb or jalap, may be taken at bedtime, and the oils, as directed above, or the compound jalap powder, the following morning; their operation being assisted by enemata, or by any gentle ape- rient conjoined with emollients and anodynes, as may be found requisite. If much disorder still continue especially of the biliary and other se- DYSENTERY —Pathology —Seat of. 693 cretions, a large plaster, consisting of the ammo- niacum plaster with mercury, and the compound pitch plaster, in equal proportions, or of the for- mer only, should be placed over the epigastrium and right hypochondrium, and renewed after a week. In some cases, the opium plaster may be substituted for the latter; particularly if the bow- els be irritated. When there is much irritation of the nervous system accompanying the disorder of the digestive canal, much benefit will accrue from the hydrocyanic acid exhibited in demulcent or diaphoretic vehicles, as the camphor or almond mixture, or in both; and from the following, espe- cially after morbid secretions have been evacuated by the foregoing means : — No. 198. R Camphors rasae et subacta gr. vj.—viij.; tere cum Magnes. ustae ^j., et Sodar Subcarbon. (vel Potas- ss Subcarb ) ?) ij.; dein addc, Infus. Valeriana? (vel Aq. Menth. Virid.) 5 vij.; Spirit. Colchici Ammoniati ^ ss.; Syrup. Papaveris ^ iij. M. Fiat Mist, cujus coch. ij. larga bis terve quotidie1 sumantur. 18. Having removed the inflammatory state, by these and other medicines appropriate to the peculiarities of the case, a similar treatment to that recommended in functional disorder of this viscus (§4.) may be adopted, and nearly the same diet and regimen pursued. At first, however, very light, and chiefly farinaceous, articles of diet should be taken, and the beverage should consist of small glasses of spruce beer, or Seltzer or soda water, and the bowels regulated by an aperient and tonic pill (F. 558. 561, 562.), or by lave- ments of warm water. As the general health im- proves, a more generous diet, and a small quantity of wine, may be taken; regular and active exer- cise in the open air being enjoyed. After the more protracted cases, or when the secretions and alvine evacuations still continue, or readily become disordered, a course of taraxacum, with minute doses of a mild mercurial, subsequently- of the nitro-muriatic acids, with compound decoction of sarsaparilla; or a course of either the Harrowgate, or the Marienbad, or the Carlsbad mineral waters may be tried. Bibliog. and Refer.—F. Hoffmann, De Intest. Duod. multorum Malorum Sede, in Opp. vol. vi.— Bonnazoli, Trans, o the Acad, of Bologna, 1745.—Schmidel, De Dig- nitate Duodeni in Dijudicandis et Curandis Morbis. Erl. 1757.—A. Monro, Edin. Med. Essays, vol. iv. ed. 1752.— CI ,ussen. in Sandifort's Thesaurus, vol. iii. 1778.—Warren, in Med. Trans, of Col. of Phys. vol. iv. p. 233.—Ferriar, Medical Histories, yl. ii. p; ^7.—G.D. Yeats, in Med. Trans. of Coll. of I'hys. vol. vi. p. 325.—Roche, et Sanson, Nouv. Element de Pathol. Medico-Chirure. kc 8vo. Paris, 1825, t. i. p. 485.—Irvine, in Philadelphia Med. Journ. Aug. 1824.—C. Broussais, Sur la Duodenite Chronique, 8vo. Paris. 1825.—Roberts, in Nouv. Bib.ioth. Med. Juin, 1828. —F. B. Boisseau. Nosographie Organique. 8vo. Paris, 1828, t. i. p. 389.—C. Hastings, Midland Med. Reporter for Mav, 1829, p. 292.—Streeten, in Ihid. for November, 1829.—"j. Abercrombie, Researches on Dis.of the Stomach and Abdom. Viscera, kc Edin. 1830, 2d ed. p. 103.—F. J. V. Brous- sais, Comment, des Propositions de Pathologie, kc 8vo. Paris, 1829, t. i. p. 297.—/?. Bright, Observ. connected wilh Dis. ofthe Duodenum and Pancreas, kc, in Trans, of Med. tod Chirurg. Soc.vol. xviii. p.1—E.A.Lloyd, in Ibid.p.57. DYSENTERY. Syn. — Jvatvran*, Gr. Dys- enteria, (from $i'-c, difficulty, and i 1 tsoui , an intestine). Difftcultas Intestinorum; Tormina, Celsus. Rheumatismus intestinorum cum Ul- cere, Caelius Aurelianus. Fluxus Cruentus cum Tenesmo; Fluxus Dysentericus; Flumen Dys- entericum; Tenesmus, Auct. Var. Dyssenterie, Flux de Sang, Fr. Die Ruhr, Germ. Dissen- terie, Ital. Bloody Flux. Classif. — 1 Class, 5 Order (Cullen). 3 Class, 2 Order (Good). III. Class, I. and II. Orders (Author, in Preface). 1. Nosol. Defin.— Tormina, followed by straining and scanty mucous and bloody stools, containing little or no facal matters; and attend- ed by febrile disturbance. 2. Path. Defin. — Inflammatory action of u, sthenic or asthenic kind, seated in the mucous surface of the intestines, chiefly of the large in- testines, accompanied with more or less constitu- tional disturbance, and retention or disorder of the natural secretions and excretions. 3. Litt. Hist. — Dysentery, owing to its prev- alence in ancient as well as in modern times, has attracted a large share ofthe attention of medical writers. Hippocrates (Opera, edit. Vander Linden, vol. i. p. 252., vol. ii. p. 101. 176. et passim) notices it in various places, both as a spo- radic and as an epidemic disease; and in such a way as shows that he was acquainted with seve- ral of its pathological states and relations, and even with its complication with functional and or- ganic disease of the liver. Celsus (De Med. 1. iv. cap. 15.) mentions it by the name of tormina, as distinct from tenesmus, from lientery (levitas in- testinorum), and from diarrhoea. Areta:us (De Sig. et Caus. Morb. Diut. 1. ii. cap. 9. ed. Boer- haave, p. 59.) attributed the complaint, with Hip- pocrates, to ulceration of the intestines; and was the first to describe it in an accurate and con- nected manner. Galen (De Caus. Sympt. 1. iii. cap. 7.), although, perhaps, not the first to distin- guish the different forms of the disease, has fur- nished us with the earliest attempt of this kind that we possess. He particularises a sanguineous, an hepatic, an atrabilious, and an ulcerated variety. Subsequent writers, — Greek, Latin, or Arabian, — down to the commencement of the sixteenth century, when the writings of the celebrated Fern el first appeared, added but little to the materials scattered through the works of Galen. From Fe rn el to the present age, the disease has been nearly as well understood, as respects both its nature and treatment, as at the present time. The numerous epidemics, however, that have oc- curred, and been described by experienced writ- ers, from the time of this physician, have furnish- ed diversified facts, illustrative of its varied forms, and of its treatment. 4. I. Seat and Forms of the Disease.— A. The ancient writers, from Hippocrates to Avicenna, considered dysentery to be seated in the internal coats of the intestines — particularly the large intestines—and attributed it too generally to erosion and ulceration. Oslius Aurelianus, Aetius, Alexander Trallianus, and oth- ers, who wrote between Galen and Avicenna, entertained the same view as to its nature and seat, and imputed the modifications it presented to the particular part of the bowels chiefly affected. They even attempted, and not without some de- gree of justice and even of accuracy, to point out, from the character of the discharges and the ap- pearance of the blood in the stools, its seat in the small intestines, in the colon, or in the rectum. Aetius (Tetrabibl. iii. s. i. cap. 43.) believed that the jejunum is sometimes the part chiefly dis- eased, and described the symptoms—many of them really concomitants of inflammation of the mucous surface of the small intestines—that characterised this variety. Similar views were 64 694 DYSENTERY —Forms or. entertained, also, by Alex an der Trallianus, Paulus /Egineta, and Actuarius. An atten- tive consideration of the various manifestations of the disease, especially in an epidemic form, will show that these opinions are not without founda- tion. How far they are consistent with the results of modern researches, will appear in the sequel. 5. B. The forms of dysentery are extremely diversified : — (a) As respects its Origin, it is — a. primary; ft. consecutive; and y. symptomatic. — (b) In regard of the Circumstances under which it occurs, it is — a. sporadic; ,-f. endemic; y. epidemic; and, f. both endemic and epidemic, in the same locality, on certain occasions.—(c) As to its Type, it is—a. remittent; and, p. con- tinued ; most commonly the latter, especially in temperate climates. — (d) As regards its Charac- ter, it is — u. inflammatory; [i. bilious-inflamma- tory ; y. simply asthenic; 8. bilious-asthenic; t. adynamic or typhoid; t. malignant or putrid; r. scorbutic; and, d. complicated.—(e) As to Inten- sity and Duration, it is — «. hyperacute; i. acute; y. sub-acute; and, S. chronic. These modifications, or varieties of character and intensity, are, how- ever, merely arbitrary distinctions, founded on the more prominent symptoms of the malady, and adopted chiefly in order to guide us in the appro- priation of remedial measures. Indeed, it should not be overlooked in this, more than in other diseases which possess very specific and distinct features in a majority of cases, that it will fre- quently assume forms intermediate between chol- era on the one hand, and diarrhaa on the other; between fever with enteric characters, and colic or simple tenesmus; that it may be but very slight- ly different from some one of these complaints; and that, in one or other of its forms, it may be consecutive of, or lapse into, any one ofthe mal- adies now named. This connection between dis- orders of parts intimately associated in function and structure, is merely what may be expected d prior»,conformably with the pathological principles developed in the article Disease. The diversified forms and close relation of dysentery to other mal- adies are readily explained on these principles; especially if considered in connection with the na- ture of the different causes in which it originates; with the condition of the vital actions, the circulat- ing fluid, and the secretions and excretions, at the time when its causes make their first impression; with the changes which concurrent causes induce from the commencement, and with the circum- stances modifying the state of the circulating and secreted fluids in the progress of morbid action. 6. In describing the varieties or states of the disease, it is of the utmost importance — consid- ering its great prevalence and fatality in cer- tain circumstances, on many occasions — not to multiply distinctions beyond such as are well ascertained and are practically important; nor to neglect to notice such as have been accurately described — as are contingent on certain combi- nations of causes of occasional, but not of common occurrence; and, although neglected or overlook- ed, from an injurious spirit of simplifying or gen- eralising, as nevertheless exist, and may be man- ifested in a prominent manner whenever the causes in which they originate prevail. Taking my own experience merely as a guide since 1812, when I first treated the disease — as I subse- quently observed it in the tracks of the great | armies which traversed Europe at the close ofthe Continental war — and as I was brought in con- stant intercourse with it for a time, in the most sickly climate within the tropics, in both Euro- pean and native constitutions — independently of the graphic delineations of it in many of the works referred to, I consider dysentery neither so simple in its nature, nor so unvarying in its seat and forms, as some recent and contemporary writers in this country have stated. That writer will but imperfectly perform his duty who, in giving a history of a most prevalent and dangerous malady, confines himself to the particular form it has as- sumed during a few seasons, within the single locality or the small circle of which he is the centre, and argues that it is always as he has ob- served it; thereby affirming as true of the genus, what may be hardly true of the species, and even of it only under certain circumstances. 7. The different forms of dysentery are so en- tirely dependent upon certain states ofthe organic or vital actions, and of the secreted and circulat- ing fluids, that these constitute the true basis of all distinctions between them, and of all rational indications of cure. These states, which are so important, are so difficult to ascertain and estimate truly, even by the most profound and experienced observers, and are so continually varying, that attempts to describe them must be received as approximations only to some of those which will frequently present themselves in practice : for the one will so insensibly pass into the other, both in different persons, and even in the same person at different stages, when certain agents are in opera- tion, that the forms of the disease are not to be viewed as constant, but as changing according to circumstances, so as frequently to assume charac- ters intermediate between those which are describ- ed. Although the features of the disease are so numerous and so changeable — as may, indeed, be expected from the operation of numerous agents in ever-varying states of combination upon the economy —yet the necessity of delineating certain of them which are the most prominent and the most common, as guides for the inexperienced, must be apparent. In our inquiries into the na- ture of, and the means of removing, morbid ac- tions, the conditions of life are the chief subjects of interest; for these conditions constitute not only the chief changes, but also the sources, whence those which are organic spring. They are, more- over, the most directly and energetically impress- ed by remedial agents, and are the chief media by which structural lesions are removed. I shall, therefore, describe the forms of this malady, con- formably with these views. It was evidently with a conviction of the practical importance of early and exactly recognising the states of organic or vital action, that J. P. Frank and Horn di- vided the acute states into (a) sthenic, and (b) asthenic; the former comprising the simple, the inflammatory, and the bilious varieties; the latter the malignant or putrid, the scorbutic, and the nervous of Richter, Kreyssig, and some oth- er authors. Without adverting to the divisions by Sag ar and Sauvages, which are formed upon no consistent principle, but chiefly upon the causes that produce the disease, I will notice such as have been adopted by some of the most experienced writers. Whilst they agree in the more general division into acute and chronic, they differ mate- DYSENTERY, ACUTE —Causes —Symptoms. 695 rially in the arrangement of the acute states. Zimmermann particularises the inflammatory, malignant, putrid, and chronic states. Richter describes the simple, inflammatory, bilious, and nervous forms; and Kreyssig adds to these the pituitous or mucous, and the putrid or malignant. MM. Fournier and Vaidy adopt nearly the same division as Kreyssig, but they adduce, in addition, the association of the disease with typhus and ague. Schiiidtmann distinguishes the simple, the inflammatory, the bilious, and bilious-inflammatory, the nervous, and the putrid varieties. M. Vignes, one of the most recent and experienced writers on dysentery, considers, first, its benign or purely inflammatory states, under the denomination of mucous and bilious; and, Tiext, its malignant forms, comprising the typhoid, adynamic, ataxic, and complicated. In the description I am about to give of the disease, I shall follow a nearly similar arrangement to the most approved of those adopted by the ablest and most experienced of my predecessors. In the first place, those acute forms will be noticed which are the most simple, which are more or less sthenic or inflammatory, and in which the vital energies are either not materially affected, or not perverted to the extent of subduing the natural tendency of the economy to resolution and to a restoration of the healthy action. Secondly, the asthenic, or more unfavourable and complicated states, which have been variously denominated, according to the predominance of certain characters, arising out of particular cir- cumstances and epidemic influences, will be con- sidered. Thirdly, the chronic and complicated forms will be described. II. Of Acute Dysentery.—i. Its Simple, Sthenic, or purely Inflammatory States. Classif.—III. Class, I. Order. 8. Defin.— Tormina, tenesmus, mucous or bloody stools, and a sense of heat or pain in the colon and rectum, with tenderness on pressure, and symptomatic fever; the nervous, circulating, and muscular functions not indicating vital de- pression until late in the disease. 9. A. Causes.—(a) The predisposing causes of the sthenic states of the disease are chiefly high ranges of temperature following wet and cold seasons; whatever favours the production and accumulation of morbid secretions in the biliary apparatus and prima via; debility of the digestive organs, particularly of the intestinal canal; a ple- thoric state of the vascular system; unnatural flexures of the colon favouring fsecal accumu- lations in the bowels; neglect of the functions of digestion and faxation; the habitual use of spirit- uous liquors, or other inebriating beverages in excess; rich food, and highly seasoned cookery. Dysentery is generally most common in autumn and in the beginning of winter; in persons of the rheumatic diathesis; and in those who have un- dergone great fatigue; or who have been recently affected by continued, remittent, or intermittent fevers; but, in such circumstances, it is as often of an asthenic as of a sthenic kind. 10. (b) The exdting causes ofthe sthenic forms ofthe disease are drunkenness; exposure to vicis- situdes of climate or of temperature, and especially to cold and moisture, or to the night-dews; sleep- ing in the open air, and more particularly on the ground, without sufficient protection intervening, or without requisite covering, as in the case of ar- mies in the field; wearing damp or wet clothes, or too thin clothing; acerb, acid, unripe, or overripe and stale fruit and vegetables; raw, cold, and in- digestible fruit, &c, as cucumbers, melons, pine- apples, &c.; the stones and seeds of fruit; unwhole- some food, especially unripe or blighted corn or rice; and acid or unwholesome drink, as sour or bad beer and wine. The exhalations from wet, cold, and clay soils and marshes, or from the banks of lakes, rivers, and canals; and the use of marsh, stagnant, or brackish water for drink, with many of the causes mentioned in connection with the other forms of the disease (§ 22. 6.), will also pro- duce this form in persons of a sanguineous and plethoric constitution. Mr. Annesley states, that dysentery became, at one time, remarkably prev- alent amongst the British troops in India to which he was attached, and that, upon investigation, he traced it to their eating the pork of the country with their breakfasts. Upon a stop being put to this practice, the disease altogether disappeared. 11. B. Symptoms and Progress.—Sthenic dysentery presents various states and grades of se- verity, depending upon the nature of the cause, the state of the secretions, and the degree of inflamma- tory irritation or of spasmodic action of the bowels resulting therefrom. It is often preceded by consti- pation when occurring sporadically, and frequently by diarrhoea when arising from endemic or epidem- ic causes; but in many instances the dysenteric symptoms appear from the first, and are attended by chills or rigors. When it is caused by endemic causes, or is epidemic, the inflammatory symptoms may be very slight, and yet the constitutional dis- turbance and morbid action of the bowels very con- siderable; or the irritation and inflammation may be along the small as well as the large intestines. 12. (a) The milder state of the complaint, es- pecially as it occurs sporadically in Europe, com- mences either with liquid and feculent, or with mucous stools, the latter being occasionally streak- ed with blood, and always becoming so in a few days. Generally, horripilations or chills precede, accompany, or follow these evacuations, which are consequent upon gripings and a sense of in- creased action in the course of the colon; and are often passed with heat or scalding in the rectum, followed by straining or tenesmus. The stools are frequent; commonly from eight or ten to more than double this number in twenty-four hours, and are streaked with more or less blood. They subsequently become less mucous, more watery, and sometimes contain traces of feeculent matter. There is little or no pain in the abdomen between the calls to stool, but often an irksome sensation is felt in the situation of the sigmoid flexure of the colon and of the rectum. The pulse is either very slightly affected, or quick and small; the tongue is generally loaded or furred; and the thirst increased. The appetite is frequent- ly not much, or even not at all impaired. This slightest grade of the disease may terminate fa- vourably in from six to nine days, or it may pass into a chronic form.—Relapses, and organic chan- ges in the large bowels, sometimes also follow it 13. (b) In its more severe stales, dysentery ia preceded either by diarrhcea, or by disorder of the stomach aud bowels; or by nausea, flatulence, constipation, and occasionally vomiting. These 696 DYSENTERY, ACUTE —Symptoms —Progress. symptoms may be of two or three days' duration, before the characteristic evacuations are observed, or be accompanied or followed by distinct chills or rigors, ushering in increased heat and frequency of pulse. In other cases, very frequent, scanty, mucous, and gelatinous motions, streaked with blood, preceded by gripings and tormina, and attended by straining, at once introduce the dis- ease. Frequently the horripilations or chills con- tinue to alternate for some time, with increased heat, and other febrile symptoms. The pain at first is often limited to the rectum and sigmoid flexure ofthe colon, occasional griping only being felt in the abdomen. The pulse is slightly accel- erated, and the tongue white and loaded. If the disease be not subdued or mitigated in this early stage, the calls to evacuation become more fre- quent; are preceded by more severe griping and tormina; are attended by greater straining; and are sometimes ineffectual. The tongue is more loaded, and the pulse more frequent and small. In many cases, however, little or no pain is felt, excepting when the patient is about to pass a motion, although the matters discharged are most morbid, and the constitutional affection severe. This, however, is no evidence of the absence of inflammation; for the mucous surface ofthe large bowels may be inflamed, and even ulcerated, and yet but little uneasiness, unless upon firm pressure, will be complained of. Often, where pain in the intervals between the tormina is absent, a sense of heat in the course of the colon, or of soreness in the abdomen, is felt, and indicates, even more than acute pain, the existence of inflammatory action. As long as disease has extended no farther than to the mucous surface of the large bowels, the patient seldom feels more than the above sensations, or a dull aching pain, not increased on pressure, which he describes as shooting, at times, through the abdomen; but when the region of the caecum is minutely examined, pain or fulness is generally detected in that situation, even when neither can be felt over the sigmoid flexure. 13. As the disease proceeds, the stools become more frequent, the tenesmus more severe, the dis- charges of blood greater and more mixed with the matters evacuated, which gradually pass from a mucous, slimy, or gelatinous, to a watery and dark muddy appearance, either with an intimate admixture of feculent matter, or occasionally with hardened faeces, and even with pure and unmixed blood. The tenesmus is now attended by a feeling as if the bowels themselves would pass off; and, in children and delicate persons, prolapsis ani not unfrequently occurs. In some instances, as the disease advances, substances resembling fat or pieces of flesh, and consisting chiefly of masses of coagulable lymph, or ofthe fibrine of the blood poured out in the bowel, come away. The urine is now, aud often early in the complaint, of a high colour, voided frequently, always with scalding pain, or difficulty; and some- times the dysuria amounts to strangury, owing to the vicinity of the chief seat of disease. The tongue is at this period loaded towards the base, and its papillae are excited. The pulse is quick and small; the skin harsh, hot, and dry, especially over the abdomen; the tormina and tenesmus in- crease, and the calls to stool are more incessant, especially during the night and early in the morn- ing, when the febrile symptoms are also much aug- mented. The thirst is urgent and the appetite lost; every thing taken to assuage the thirst being fol- lowed by tormina, and a desire of evacuation, as if it had rapidly passed through the bowels; and the patient desponds. Subsequently pain becomes more fixed in the hypogastrium, the abdomen more tense, full, or tender; the strength sinks; and dyspnoea sometimes supervenes,— indicating the extension of inflammatory action to the peritoneum. If no amelioration take place before the appear- ance of these latter symptoms, the pulse becomes more quick and feeble, the extremities cold; the tongue either brown, or dry and hard, or glazed, red,and aphthous; the strength more reduced, the emaciation great; the discharges dark, watery, offensive, cadaverous, and like the washings of flesh; and the spirits dejected. Hiccup sometimes occurs; with delirium, relaxation of the sphincter ani, leipothymia, and death, at a period varying from a fortnight to three or four weeks. In other instances, the disease is arrested some time before dangerous symptoms supervene, or is mitigated only, and thence passes into the chronic form. 14. Simple dysentery presents every grade of severity between the two now described; and such are the most common appearances which it assumes in this and in temperate climates; but the symptoms often vary much, according to the causes, the age, and strength of the patient; the parts of the canal first affected; the pre-existence of collections of morbid secretions or frecal matters, the external agents operating during treatment, and the means employed. To some of these modi- fications and their pathological relations it is ne- cessary to advert. When it arises sporadically, febrile action, ushered in by chills or rigors, seldom is observed until the dysenteric symptoms are formed, and is merely symptomatic of the local disease, which may commence in the caecum, or in the colon and rectum, or in this last, and be there in a great measure limited, or may extend more or less to other parts. Thus patients are frequently affected with diarrhcea, uneasiness and fulness of the abdomen, particularly in the region and vicinity of the caecum, several days before mucous and bloody stools or straining are com- plained of, especially when the disease is conse- cutive of fever; and occasionally they experience tenesmus some days before the disorder is fully formed. In these cases, the progress of affection from the caecum, or even from the small intestines, along the colon to the rectum, as well as in the opposite direction,may be traced by the symptoms, when the patient comes early under treatment. In other instances, especially those consequent upon fever, and in some epidemics, febrile action may co-exist with, or even precede, the earliest symptoms. It is, therefore, important, in a prac- tical point of view, to ascertain the early seat and extent of morbid action, as well as its constitutional relations; as, together, they furnish the chief basis of therapeutical indications; for, in proportion as constitutional disturbance is great, previously to the formation of the bowel affection, the less should antiphlogistic or depletory measures be relied upon in the treatment. In general, although the straining be severe, and the calls to stool fre- quent, yet if uneasiness or pain be not occasioned by pressure over the region of the caecum and sig- moid flexure of the colon, if heat in the course of the colon be not felt, and if tormina be not DYSENTERY, HYPER-ACUTE —Symptoms. 697 violent, nor the abdomen tense or tender, the rectum may be considered the chief seat of the disease; the secretions poured out in the upper parts of the intestinal canal having produced, first, irritation, and afterwards, inflammation of this part. But, if there exist much primary consti- tutional disturbance, this inference should not be drawn; for, in sach cases, the mucous surface of both the small and the large bowels may be Beriously affected, and yet these symptoms may not be present in any evident degree. Cases will also occur, characterised by tormina, twisting pains about the umbilicus, borborygmi, tension of the abdomen, more or less febrile commotion, and frequent calls to stool; the evacuations being mucous, bloody, and subsequently watery, &c. ; and yet little or no tenesmus will exist. In these, the seat of disease is chiefly the ilium, the caecum, and upper part ofthe colon; which often become speedily ulcerated if the morbid action be not arrested. When, in addition to these symptoms, tenesmus is urgent, the rectum and sigmoid flexure of the colon are also affected. 15. In this form of disease, the quantity of matters evacuated from the bowels is extremely various. In severe or advanced cases, from twenty to thirty, or even forty, efforts at stool are sometimes made in the twenty-four hours, and often without any further discliarge than a little mucus and blood; but occasionally much serous or watery matter, with broken-down faeces, slime, mucus, and blood, is voided, exhausting and emaciating the patient. In some instances, the evacuations are muco-puriform, more or less streaked with blood, without the least trace of feces; and in others, they contain scybake. It would seem, that the retained faeces are frequently broken down or semi-dissolved by, and mixed up with, the serous and sero-sanguineous fluid exhaled from the irritated mucous surface; and hence the infrequency of scy bate in many statesof the disease. The evacuations are often very offensive from the commencement, but as frequently they are not manifestly so. They generally become fcetid, or have a peculiar raw cadaverous odour in the last stage of the worst cases; especially when portions of the mucous surface are sloughed off. They are sometimes of a singularly variegated hue; con- sisting of glairy mucus, with a greenish or gela- tinous substance, resembling morbid bile; seldom with pure bile; often without any trace of this secretion; occasionally with large pieces of albu- minous concretions of coagulated lymph or fibrine, formed upon the internal surface of the bowel, and afterwards detached; and either with streaks of fluid blood, or with small dark coagula. When the blood is in large quantity, and is fluid and distinct from the other matters, it is evidently poured out by the lower parts of the large bowels. When consisting of dark grumous clots, intimately mixed with the discharges, it probably proceeds from the caecum, or upper portion of the colon. It may, or may not, even when most copious, depend upon ulceration; but it most commonly is exuded from the irritated mucous surface, espe- cially early in the disease. It may be very abun- dant, even at this stage, and continue so till death, particularly in drunkards; or it may be trifling throughout; or be copious only at the close of the disease. 16. The state ofthe abdomen also varies. In 59 some, tension with fulness, proceeding generally from faecal accumulations; and flatus is much complained of from the commencement In others, the abdomen is natural in size. Pain and tenderness on pressure are uncertain sympoms in the early stage of the disease. When it is fixed in one piace, we should suspect inflammation or disorganisation to be proceeding there. It is, in the plethoric, most frequently complained of in the hypogastrium and region of the caecum; and it may often be traced up the right side and in the course of the colon. Often there is little or no pain, nor even soreness; the patient bearing pressure without expressing any uneasiness, and yet, upon examination after death, the morbid ap- pearances will be as extensive, in respect of the inner surface of the bowel, at least, as in those who complained of the greatest pain; the chief difference being in the more complete limitation of the lesions to the mucous surface in those cases wherein no pain was felt. It is chiefly in the last stage, when inflammatory action has extended to the serous surface of the bowels, that fulness, pain, and tenderness of the abdomen have been complained of. ! 17. (c) Hyper-acute dysentery, or dysentery in Europeans removedto warm countries, is generally occasioned by a too rich and stimulating diet, and a regimen entirely unsuited to the climate; by the too free use of ardent and intoxicating liquors; by exposure to the night air, or to cold and moisture; and by the endemic and other causes mentioned above (§§ 9, 10.). It often assumes j the severe character now described; and, in per- | sons who are plethoric, who have neglected their [ bowels, have lived highly, or are of a phlogistic diathesis, or who possess rigid fibres and great irritability, it puts on a still more violent or a super-acute form. In them, the sense of heat and soreness; the tormina, fixed pain of the hypogas- trium, the tension ofthe abdomen, the continual calls to stool, and thestraining, are most distressing. | The region of the caecum is full and tender. The | tongue is white, loaded, excited; sometimes clean and natural, but afterwards dry. The skin and I pulse are frequently, at first, and for some time, | very little affected; the constitutional disorder not being commensurate with the severity ofthe local I symptoms; but the former subsequently becomes dry or hot, and the latter quick, hard, and small. In many cases, the disease begins as common diarrhcea; in others, it comes on suddenly, and rapidly reaches its acme; and then the thirst is excessive; the urine scanty, voided with great pain, or altogether suppressed; the testes drawn up to the abdominal ring; the stools mucous, | slimy, streaked with florid blood, sometimes at- i tended by prolapsus ani, and rapidly passing to watery, serous, or ichorous discharges, resembling I the washings of raw beef, in which float particles, or even large shreds of coagulable lymph, thrown off from the acutely inflamed surface, often with copious discharges of blood, (treat depression of spirits, nausea, vomiting of bilious matters, and i distressing flatulence or borborygmi, which ag- gravate the tormina, are also present, and, in many ofthe fatal cases, contiuueto the last. In some of these the inflammatory action extends to the sub- mucous coats, and detaches portions ofthe mucous tissue, which come away in the stools, in the last stage, or even hang from the rectum; any effort 698 DYSENTERY, ASTHENIC —Causes. to withdraw them occasioning a remarkable in- crease of suffering. The constitutional disturbance has now become very severe, and a fcetid or ca- daverous odour proceeds from the patient. De- tached portions of the mucous membrane will be recognised by their sloughy appearance; by the ichorous character and putrid smell ot the &» charges which contain them; and by the period at which they are observed, the albuminous exuda- tions that resemble them being thrown off at an earlier stage. 18. In somewhat less violent and more pro- tracted cases, especially as the disease approaches an unfavourable close, the motions are sometimes streaked with a puriform sanies, or with a whitish, opaque, or greyish matter, apparently depending on ulceration; and they frequently are involun- tary, owing to the paralytic state of the sphincter, the anus being excoriated, livid, relaxed, and widely open. The surface of the body, also, is shrunk, occasionally yellowish; the superficial veins deprived of blood, and the extremities moistened with a cold sweat. At last, the patient is affected by leipothymia, or stupor, or by deli- rium, and other nervous symptoms, and dies in from four, five, or six days, to three weeks, unless the disease is of a milder or more chronic form, or is arrested by treatment 19. In Europeans, long resident in an inter- tropical or hot country, the disease assumes either a less inflammatory form than the preceding, or some one of the asthenic states about to be de- scribed; it also frequently becomes chronic in them, and is often consequent upon, or asso- ciated with, ague, remittent fever, or with diseases ofthe liver, spleen, and other abdominal organs. (See § 20. et seq., and Complications.) ii. The Asthenic Forms of Dysentery. Classif.—III. Class,XI. Order (Author). 20. Defin.—Depression ofthe organic actions; ofthe tone ofthe drculating, nervous, and mus- cular functions, preceding or accompanying the occurrence of tormina and tenesmus, with mucous, bloody,and offensive stools, andgiving rise tofa- tid exhalations, and infection in confined places and predisposed persons. 21. The asthenic forms of the disease have been variously denominated, according to the more prominent features assumed by them under certain circumstances, endemic as well as spora- dic, and especially in different epidemics. Whilst the foregoing states are generally attended, espe- cially in their early stages, by sthenic vascular action, those about to be noticed are usually cha- racterised by fever, of a low, nervous, or adynamic kind; by greater prostration of the constitutional powers than the preceding; by an earlier mani- festation of febrile commotion or constitutional affection, which may even precede the dysenteric symptoms; and by a much more remarkable affection of the whole economy: and while the above forms are generally sporadic, sometimes en- demic, and seldom epidemic or infectious, those about to be described are commonly epidemic and infectious, under circumstances favourable to this mode of propagation; sometimes endemic; and more rarely sporadic, excepting in the darker races ofthe species, in which it is extremely apt to become infectious, when occasions promote its spread in this manner. 22. A. Causes.— (a) The predisposing causes ofthe asthenic forms of dysentery are, chiefly, epi- demic states of the atmosphere; cold and variable weather after long heats, or after hot and moist seasons; prolonged heat and humidity; accumu- lations of morbid secretions in the prima via; a cachectic habit of body; deficient and unwhole- some food; pre-existing debility, especially that caused by low fevers; an impure and miasmatous state of the air, especially when connected with humidity; worms in the prima via; and the pre- disposing causes already enumerated (§ 9.). (6) The exciting causes are, famine or pro- longed fatigue; exposure to a moist cold; the excessive use of intoxicating liquors; exhalations from animal and vegetable matters in a state of decay; the use of marsh, stagnant, or river water holding decomposed animal and vegetable matters in solution, or containing, either with or without these, animalcule and minute insects, or of brackish waters; the flesh of diseased animals, or meat kept too long, or tainted; stale fish; blight- ed, unripe or ergoted rice, rye, &c. ; unwhole- some or insufficient food; breathing the stagnant or infected air of low, crowded, and ill-ventilated places, especially when a case of the disease occurs in such circumstances — as in hospitals, camps, prisons, ships, barracks, &c. ; and the exhalations proceeding from the discharges, and from the sick, either confined and concentrated in a stagnant, or floating in a warm, moist, mias- matous, or epidemic atmosphere. But there is reason to suppose, that the concurrence of two or more of the causes enumerated in connection with the sthenic states of the malady will also produce some one of its asthenic forms, during certain conditions of the air which have been called epidemic, especially in persons of a weak frame and depressed vital and mental powers. The least energetic, also, of the above causes, acting on persons already affected by the preceding form ofthe disease, will convert it into some one ofthe asthenic states. Owing chiefly to the diversity of the exciting causes, to their concurrent operation, and to the difference in the state of constitutional predisposition, &c. are to be imputed the modi- fications which the disease presents when epidemic, or at different seasons. 23. a. Ofthe influence of exhalations from ani- mal bodies in a state of decomposition, in causing the low forms of dysentery, I could produce, if my limits would permit, numerous proofs. One ofthe authors of the article Dysentery, in the Diction- naire des Sciences M&dicales, states, that, having been detained on horseback in a field of battle, in August, 1796, where several hundred men and horses lay in the first stage of decomposition, he was seized with a dangerous dysentery on the following day; that three out of four of those who accompa- nied him were similarly infected; and that his horse died of the same disease soon after. Similar facts are adduced by Zimmerman n, Osiander, Des- gen ett es, and others. Ofthe agency of impure water, in producing dysentery, proofs are like- wise numerous. I have myself seen several in- stances, in a warm climate, where it was the cause of the disease being endemic there. In temperate countries, waters containing decayed animal matters, or an excess of uncombined alkali, cause diarrhcea more frequently than dysentery, or the former passing into the latter. But in warm climates, especially where water is collected and DYSENTERY, ASTHENIC —Forms and Symptoms. 699 preserved in tanks, and in autumn, after warm summers, in colder countries, dysentery is the most common result. The water of the Seine at Paris, from this cause, often produces the disease; and Dr. M. Barry states, that such of the inha- bitants of Cork as used the water of the river Lee, which receives the contents of the sewers, and is, moreover, brackish from the tide, are subject to a very fatal dysentery; and that, at the time to which he especially refers, at least one in three of those affected died of it I have no doubt that the dysentery epidemic in London, during several successive autumns after the great plague, was owing to the same causes, as well as to the exhalations from the burying grounds, which received the bodies of those who died of that pestilence; and that the prevalence ofthe disease in besieging, as well as in besieged armies, is caused by the exhalations from the decomposition of the dead; by the impure state of the water, from decomposed animal matter carried into it; by night exposure; irregular living, deficient food or clothing, and the other contingencies on en- campments and operations in the field; and by crowded and ill-ventilated barracks, &c. The frequent occurrence and fatality of dysentery in fleets, iu former times, evidently arose from the putrid state of the water, and the foul and stag- nant air between decks, sometimes breathed by several hundred persons. During the slave trade, dysentery was, and even now is, among the nume- rous small vessels engaged in this disgusting traffic, the chief pestilence; one half of those conveyed in these floating receptacles of misery, on some occasions, having died of it during the passage across the Atlantic. It may be here mentioned, that the dark races, particularly negroes, are more liable to dysentery than to any other disease; that it assumes an extremely low or putrid form in them, when confined in ill-ventilated situations; and that, when a number, even of those in health, are shut up in such places, the cutaneous secre- tions, which are so abundant and offensive in these races, accumulate in and vitiate the sur- rounding air, so that if it be not frequently renew- ed, the systems of those thus circumstanced are thereby infected, and, instead of an infectious ty- phus, which would be the result in the European constitution, a putrid dysentery, spreading rapidly through all breathing the impure air, is developed. I had, in 1817, an opportunity of witnessing what I now state. The disease is considered by the native Africans as infectious as small-pox, and is dreaded by them equally with it; these two being the most fatal diseases to which they are liable. 24. p. The contagion of dysentery has been much disputed; chiefly owing to the circumstances of the different forms of the disease not having been distinguished with any degree of precision, and of the loose notions attached to the words contagion and infection, by those who espoused different sides ofthe question. In the article Infection, these terms, and their true value, are attempted to be estimated with more precision than heretofore. As respects this malady, it may be stated, as the result of observation and acquaintance with what has been written, that the sthenic forms are seldom or never infectious—aud chiefly for this reason, that the circumstances in which they occur are unfavourable both to the generation of infectious emanations, and to their accumulation, concentration, and operation in healthy persons— that, in short, they, like all other sthenic maladies, do not evolve infectious effluvia, because the vital energies are not depressed nor perverted to such a degree, even in their advanced stages, as to give rise to the depravation of the circulating and secreted fluids requisite to the production of infectious emanations, these changes taking place only when some one or more of the causes which produce these effects—the causes of the asthenic states—come into operation;—that febrile diseas- es, attended by depravation of vital power and of the fluids, evolve effluvia capable, under favour- able circumstances, of infecting or contaminating those disposed to be impressed by them;—and that, as the asthenic forms of dysentery are char- acterised by these properties, and as the emana- tions disengaged in their advanced stages become cognisable to the senses, as well as by their effects, it must be inferred, that these forms are infectious on occasious favourable to the action ofthe emana- tions which proceed from them. These inferences, founded on an important pathological principle, are confirmed by enlightened and most numerous ob- servations; and, independently of such confirma- tion, this principle must be shown to be unfounded before the inferences drawn from it can be denied. Thus it will appear that the great difference of opinion that has existed on this subject is to be referred, first, to the fact that certain states only of the disease are infectious, and these chiefly in circumstances favourable to the development and operation of the infectious emanation; and, sec- ondly, to the incorrect notions entertained respect- ing contagion and infection; many believing, be- cause the disease is not propagated by mediate or immediate contact of the diseased person, or of a palpable secretion or virus, that therefore no contagion nor infection is produced by it But the spread of dysentery very closely resembles that of scarlatina or measles, which cannot be propagated by inoculation, or by the application, either direct or indirect, of the morbid secretions to a confined part of the external surface; and yet the effluvium from the sick or the faecal evac- nations, floating in a close or stagnant air, will readily induce the disease, in persons who, con- stitutionally, or from the influence of concurrent causes, are disposed to it, and who breathe the air thus contaminated. In such cases, the effluvi- um operates, as in other infectious diseases, chiefly through the medium of the respiratory organs; the system being affected, although not very manifestly, before the dysenteric symptoms are developed. Several respectable authors, however, have conceived it to be propagated, when persons repair to the water-closet or night-chair used by dysenteric patients, by the action of the infected air or effluvium upon the anus, the affection ex- tending upwards, along the rectum. Hufeland and some others state, that they have seen the complaint communicated by the pipe of an enema apparatus. But, in most of the instances of the infectious disease that I some years ago had an opportunity of seeing, constitutional disturbance, and often diarrhcea, preceded the fully-formed dysentery. 25. B. Forms and Symptoms.—u. Thesimple sthenic or adynamic dysentery. This variety is one of the most common, particularly in this country. It may occur sporadically in delicate persons, 700 DYSENTERY, ASTHENIC —Typhoid — Putrid. owing chiefly to the more debilitating causes as- signed above. It is also frequently epidemic, especially among the poor in times of scarcity, and after very wet and warm seasons; it often follows attacks of adynamic fevers, or prevails at seasons when they are prevalent. It was epi- demic in Glasgow in the autumn of 1827; and is described by Mr. Wilson, Mr. Brown, Dr. Macfarlane, and Mr. Weir (Glasgow Med. Journ. vol. i. pp. 39. 48. 99. 223.) It generally commences with diarrhcea, succeeding a consti- pated state of the bowels; and very frequently, especially in the more severe cases, coldness, chills, or rigors are observed, attended by griping pains about the lower part of the abdomen, with fre- quent calls to stool; and sometimes followed by fixed pain in the hypogastrium, particularly at its right and left sides. Want of appetite, increased thirst, furred tougue, clamminess of the mouth, and acceleration of pulse, usually are superadded. As the disease becomes fully formed, the pulse is more or less frequent, small, weak, and soft; the skin is sometimes but little warmer than natural, or only hotter over the abdomen: it is commonly harsh and dry. The countenance is pale, shrunk, and anxious; sickness and vomitings occasionally occur; and singultus is not infrequent in the latter stages, when the tongue, from being white, slimy, furred, and yellowish, generally becomes red, glazed, and chapped, and occasionally dark red and dry. The stools sometimes are not mucous, slimy, or bloody, although very frequent, until the second, third, or fourth day; but, in other instances, they present these characters from the first They are always of this description as soon as chilliness or rigors are felt. The evacua- tions vary greatly in frequency and quantity; but they are generally characterised by a deficiency of bile, by great feetor, and by the absence of scybala, excepting in a very few cases. Remis- sions of the symptoms, and of the urgent calls to stool, often occur about the middle of the day. The tormina and straining are sometimes followed by prolapsus ani, especially in children and deli- cate females. In a few instances, a puriform fluid is voided towards the close of the disease. The urine is usually scanty, passed with pain, and rarely retained. This is the least infectious of any of the states of the disease comprised under this species; unless in close and crowded places; and then it manifests this property, and passes into some one of the states next to be described, particularly the typhoid. 26. p. The nervo-adynamic, or typhoid. — Asthenic dysentery sometimes appears in a modi- fied form under certain circumstances, especially where numbers are collected in a close and impure air, as in barracks, garrisons, crowded ships, &c; and in years of scarcity among the poor. The patient complains at first of general depression, vertigo, violent headach, increased sensibility to light, pains in the limbs and joints, and of grip- ings and purgings; followed by anxiety at the praecordia, stupor; foul, clammy tongue and mouth, which soon becomes dry and covered by a brownish coating; a penetrating, offensive odour of the breath; and intense thirst. The pulse, at first, is very quick and small; and, after- wards, weak and irregular. The stools are, from the commencement, very frequent, in small quan- tity, preceded by tormina and tenesmus; aud glairy, or serous, very foetid, and contain more or less dark blood. The urine is scanty, thick, and dark-coloured. About the fourth or sixth day, a miliary eruption, or petechias, sometimes appear about the neck, breast, arms, or abdomen; and, occasionally, epistaxis occurs, between the fourth and eighth days, in young and robust subjects, but without becoming critical. The intensity of the tormina and tenesmus generally diminishes with the progress ofthe disease; and often, about the ninth or eleventh day, is replaced by a col- liquative diarrhcea. The stupor is now attended by low delirium; the soft solids waste and be- come flaccid; the surface assumes a dirty hue; and an offensive penetrating odour issues from the body and the evacuations. If not ameliorated, or arrested in its progress, this form terminates fatally from the sixth to the twenty-fourth day, the symptoms described (§13. 18.) as indicating a fatal issue supervening. Such are the charac- ters it usually assumes; but they are modified by age, constitution, and concurrent causes. It is less frequently epidemic than the other asthenic states, but is more evidently infectious than they. 27. ;•. The malignant, or putrid.—This form is most common amongst the poor, especially in years of scarcity; in soldiers, during campaigns; in besieged towns, and in countries laid waste by war, &c. It also arises from the existence of en- demic causes in full force, especially those which occasion malignant fevers—as animal and vegeto- animal exhalations floating in a warm and moist air; foul water, and other septic agents. It usually commences with a general feeling of debility, las- situde, and aching pains, referred particularly to the limbs and joints; with anorexia; foul, loaded tongue; sometimes nausea, borborygmi; relaxed bowels; pale, sunk, or anxious countenance; gid- diness; and with a small, soft, frequent, and sometimes slow or natural pulse. To these su- pervene griping pains in the abdomen, followed by foul, offensive, scanty, and bloody stools; some- times without tenesmus, particularly at first. Hor- ripilations, or chills, rarely rigors, sometimes occur, at irregular intervals, during the early progress of the disease; but they are often absent. '1 he mental energies are greatly depressed, especially as the disorder advances; when the tongue, which was moist and slimy, becomes covered by a dark, mucous, or fuliginous sordes; the breath is fcetid; and a dark mucus occasionally collects about the sides of the tongue and on the lips; or aphthae form in this situation. Tenesmus is now com- plained of; and the stools are cadaverous, watery, dark, and bloody; the soft solids flaccid; and the skin harsh, dry, and of a sickly, dirty, sometimes approaching a yellowish, hue. The patient after- wards sinks into a state of complete apathy; but stupor or delirium seldom comes on until shortly before dissolution: the position in bed is supine; the dejections are involuntary, frequent, and mix- ed with dark blood, often followed by syncope or leipothymia; the temperature of the extremi- ties sinks rapidly, whilst it continues much higher over the abdomen; the urine is scanty, dark, and fcetid; and the body exhales an infected odour. Anxiety at the pra;cordia, singultus, and difficult deglutition supervene; and the patient sinks in from five to sixteen or twenty days, according to the violence of the symptoms. This form of the disease is frequent in the most miasmatous DYSENTERY, ASTHENIC— Bilious Adynamic. 7Q1 localities in hot climates, both among natives and seasoned Europeans, particularly when remittent fevers are prevalent or malignant; and it occa- sionally assumes a remittent type, when it may be prolonged to twenty-eight or thirty days. I saw many cases of it in Africa, in 1817 and 1818.* 28. A. The bilious adynamic. — When bilious, remittent, and gastric fevers are prevalent, a form of dysentery often also prevails, very nearly re- sembling the first or simple variety; and differing from the foregoing or third form, chiefly in pre- senting more evident attempts at vital and vascular reaction than it. The present variety tometimes appears, sporadically, in autumn and winter; it is often endemic, in hot climates, among Europeans, arising from the same causes as endemic fevers, aided by cold and moisture; and it occasionally prevails, or becomes epidemic, in temperate coun- tries, during autumn and the beginning of winter, especially after hot summers. This and the im- mediately preceding variety frequently co-exist, in the same localities, in warm climates, or after hot seasons in temperate countries: this, in the ple- thoric, sanguine, and robust; that, in the debilitat- ed, ill-fed, and weakly constituted. Bilious adyn- amic dysentery is generally caused by a less in- tense operation, relatively to the powers of the constitution and to the predisposition, of the same exciting causes, particularly such as are endemic, as those which occasion the malignant form. I have seen it prevalent in Europeans, in warm climates, in the same locality and in the same season as when that form was most destructive in the dark races. Many epidemics recorded by au- thors belonged to the present variety; although, during an epidemic dysentery, more than one form or state of the disease will be met with, owing to the different circumstances, intrinsic and extrinsic, as respects those affected, in which it will occur. 29. This variety generally commences with bilious or serous diarrhcea, which may continue for several days; with debility, pain in the fore- head, vertigo, and a mucous yellow coating on the tongue. To these supervene horripilations, chills or rigors, tormina, very frequent calls to stool, a sense of scalding at the anus, and tenes- mus. The chilis often return during the early stages, and are followed or accompanied by a frequent, hard, or irritable pulse, great thirst, and an acrid heat ofthe trunk, especially over the ab- domen. Nausea, sometimes vomiting, want of appetite, loathing of animal food; a sense of heat in the abdomen; fulness in the seat of the caecum; pain above the pubis ; complete prostration of strength, referred chiefly to the spine and lumbar region; and scalding on the passage of urine; are commonly present at an early period. The pulse, from being quick and irritable, becomes soft; subsequently, small, irregular, and very weak. The stools sometimes continue copious and yel- * Most ofthe crew ofthe ship in which I was a passenger to that country were treated by me, for seasoning and remit- tpnt fevers, soon after their arrival. They all recovered before I reached my destination. The vessel subsequently went in pursuit of frame up one of ihe rivers in the bay of Benin, where the crew there became ill of this form of dys- entery ; of which all died excepting the second mate and carpenter, whom I chanced, long afterwards, to meet in England. Not one third of the crews of the many vessels that proceed up these rivers survive this disease and fever. The men who are often deceived into undertaking the voy- age, have not even the benefit of medical aid ; for none of hese vessels is provided with, or is within reach of, this kind f assistance. 59* lowish for two or three days; but they are usual- ly streaked with blood at the time when tormina and tenesmus are complained of, or soon after- wards. As the disease advances, the blood is more abundant: either mixed with the stools, or fluid and distinct, or in large coagula, and usually of a dark colour; and the abdomen becomes tense, or tumid and tympanitic. The frequency and the quantity of the stools vary greatly; but the dis- tress and tormina are worst at night, the abdom- inal pain and uneasiness occasionally remitting in the morning, or subsiding for a short time after each evacuation. The odour ofthe discharges is, from the first, fcetid; and, in very severe cases, it becomes putrid and cadaverous. With the pro- gress of disease, emaciation proceeds rapidly, the surface being harsh, and of a dirty appearance. Towards an unfavourable state, the temperature sinks; the tongue being dry, dark-red, or raw; and anxiety, restlessness, singultus, delirium, lei- pothymia, with other symptoms described as char- acterising the last stage of the preceding variety (§ 27.), supervene. This form is seldom pro- longed beyond twenty-six or thirty days; unless it assumes a milder aspect in its progress, when it often passes into the chronic state. It is frequent- ly epidemic after hot and moist seasons.! t Epidemic dysentery often presents various modifications, in respect both of violence and of the occurrence of phe- nomena not commonly observed. Of these latter, the most frequent are burning pains or great heat in the abdomen; whilst the extremities and surface are cool or even cold, and the pulse sometimes not much affected ; boulimia ; very co- fiious, mucous, bloody, or gruelly and frothy, or, more rare- y, oleaginous, evacuations; great weakness of the lower extremities , gangrenous eschars ; a parchment-like or scaly state of the skin ; hematuria, or entire suppression of urine ; an aphthous state of the mouth and throat; retraction of Ihe abdomen, or the great tension, fulness, or meteorismus of this cavity ; frequently the excretion of worms in the stools or by vomiting ; miliary, petechial, phlyctenous or tubercu- lar eruptions on the trunk; catarrhal or pneumonic symp- toms; and rheumatic pains in the muscles and joints. Gen- erally, as the quantity of fluid matters evacuated from the bowels are increased, the excretions by the kidnevs and skin are diminished. In most epidemics, especially those of the asthenic forms, constitutional symptoms, characterised by lassitude, debility foul tongue, disordered slate of the stom- ach and bowels, unhealthy aspect of Ihe countenance and skin, and weak, quick, and soft pulse, with evident disorder ofthe circulating and secreted fluids, precede the pathogno- monic symptoms, which appear after these have continued a loneer or snorter time. It will be instructive to review the characters of and the remedies employed in, those epidem- ics of which we have authentic accounts, as valuable illustra- tions of the nature and treatment of this destructive malady will be thereby furnished. It will, moreover, appear, even from the very meagre account to which my limits oblige me to confine myself, that our knowledge of the disease even at the present day, is hut little in advance of what existed two centuries ago ; and that even the most recent writers on the subject are distinguished rather by confined or exclusive ideas as to its nature and treatment, than by comprehensive views of its forms and manifestations, as well as of the means of re- moving it, in connection with the various combinations of causes producing it. and the diversified circumstances in which it prevails. Exclusive notions of a disease are the re- sult of a knowledge merely of what has occurred with u Ihe sphere of the author's observation ; whilst more extended ideas are acquired from what he has remarked in various climates, on different occasions, and at distant periods, and from an acquaintance with what has been observed by others: believing, truly, that nothing is constant but change; that what has occurred or prevailed formerly will recur again ; and that one form is as likely as another to appear in future, whenever the concurrence of causes, of which it is a neces- sary or contingent result, shall take place. 1. Gregory of Tours states that dysentery ravaged the whole of France in 334. 2. Its destructive effects in the army of HENRY the Fifth, before and after the battle of Azicicourt, are well known. 3. FERNEL says that, in 1538. it was so general through Europe, that neither village nor town escaped, although the seasons had been regular. 65 702 DYSENTERY —Epidemics. 30. f. In the Dork Races, dysentery is perhaps the most prevalent and fatal disease ; and in 4. Cameraru's observed it, in the autumn of 15S3, in Germany, where it was malignant and destructive. The preceding summer had been hot and dry. 5. Za utus (Curat, cent, iii.) notices an infectious and destructive dysentery in Lisbon, in 1600, for which fumiga- tions were employed.. 6. Lammoniere describes it as it occurred in Lyons, in 1607, 1624, and 1625, where it had beeu imported with the troops from Italy. In proof of its infectious nature, he states that the medical attendants and nurses were nearly all attack- ed. Marks of inflammation and gangrene were found from the pylorus to the anus, the liver and omentum being also disorganised. 7. Sennert (Mid. Pr. I. iii.) mentions an epidemic which pervaded all Germany in the summer and autumn of 1625; and Hoffmann stale , that it reappeared in autumn 1626, after a wet and warm spring, and a dry and hot sum mer ; that it was contagious ; and was best treated by bleed- ing at the commencement, in some cases, by laxatives and demulcents, by nitre and absorbents, and by milk with Seltzer water. 8. DlEMERBROECK records, that the disease was most fatal in Brabant, in 1635, then the seat of war. It first ap- peared amongst the troops, and afterwards among the inhab- itants. The prostration of strength was great; and infection was proved by the attendants having been all affected. The most successful remedies were rhubarb, and, afterwards, one or two drachms of wax melted in warm milk. 9. Bartholin relates, that a malignant dysentery suc- ceeded to ague ii. Copenhagen, in 1652, and carried off many thousands. The odour of the evacuations was most offensive. 10. The plague of London, in 1665, was followed, in the autumn of i666, by an epidemic and infectious dysentery. MORTON was attacked, and escaped with difficulty. It ap- pears to have been occasioned by the infected air emanating, in the summer, from the numerous bodies buried in and about London during Ihe preceding year. The fatality was very great; and cinchona seemed to have been the chief remedy. 11. In an epidemic described by W. Wedel (Act. Nat. dec. ii.), and which occurred, in 1669, at Gotha, ihe evacu- ations were ftetid and sanguinolent; and yet, in many in- stances, unattended by pain or tormina. Those in whom the tormina was most severe, recovered ; but those who experi- enced no pain died suddenly, the disease having passed rap- idly into gangrene. 12. Sydenham states, that the cholera which prevailed in London, in the summer of 1670, having ceased, dysentery took its place. The disease commenced with chills or rigors, followed by increased heat. The treatment was directed to remove inflammation, and evacuate morbid humours. 13. Brandt notices the occurrence of dysentery, in an epidemic form, in the Danish army, and in Copenhagen, in the summer of 1677 ; and attributes it to the use of stagnant water and of bad beer, and to an atmosphere loaded with impure exhalations. i4. Dysentery prevailed in Zurich in August, in 1680, after a hot summer. It appears from Muralto to have been of an inflammatory type. 15. An epidemic, observed by F. Hoffman v, in 1684. in Westphalia, was also inflammatory. Favourable cases ter- minated by the fourteenth day; those that were prolonged beyond it, generally terminated unfavourablv. Persons in communication with the sick were infected. Bleeding at the commencement, and nitre with camphor, were the chief remedies : astringents and stimulants were injurious. 16. LOESCHER states that the epidemic dysentery of 1709, in Misnia, was attended by acute fever petechia;, lividity of the countenance, meleorismus of the abdomen, and depres- sion of strength and of the pulse ; followed, in many instanc- es, by delirium, convulsions, and death. Clysters, ipecacu- anha, laudanum, and sometimes bleeding, were employed. 17. In August, 1718 the disease appeared, in a malignant form, among the Prussian military in Berlin and Pomeran a, and extended o the inhabitants. Aphtha; were a common and an unfavourable symptom. A change usually occurred towards the fourteenth day. Relapses were fatal Evacu- ants and diaphoretics, followed by tonics and antiseptics, were the most successful means. 18. MARGRAAF details the history of an epidemic which, in some cases, was mild and remittent; but, most commonlv, of the bilious-adynamic and malignant forms. Ipecacuanha was the most useful medicine. 19. A similar visitation took place at Nimeguen, in 1736 (Degner). The malignant cases were frequently fatal on the third or fourth day, and were contagious. Ipecacuanha, rhubarb, and, subsequently, simarouba, were chiefly confid- ed in. 20. Dysentery was epidemic in Plymouth, in 1744 (Hex negroes it generally takes the place of fevers; being, in the language of Sydenham, a low fever HAM), in an inflammatory form. Early bleeding, ipecacu anha, rhubarb, and, at the close, opiates, were the chief remedies. 21. It prevailed in Zurich, in 1747, and was attributed to bad water (Gruber.) Diaphoretics emollients, opiates, and tonics were most generalk prescribed. 22. It was the most destructive disease in the British army in Holland, in 1748 ; and was acutely inflammatory, often rapidlv terminating in gangrene GraInoer, kc). Bleed- ing, emetics, and purgatives were employed. 23. The epidemic, in several parts of France, in 1750, was chiefly of the simply asthenic and malignant forms. A-tringents were injurious evacuants, emollients, and anti- septics being most serviceable (Marteau and Navier). 24. That which occurred in Hanover (Lentin) was at- tended by a burning heat in the abdomen, without much at- tendant general fever ; and by foetid or purulent stools. An- timony, rhubarb, mucilages, and, afterwards, simarouba or copaiba in the yolk of egg, were usually directed. 25. STRACK states that the French army brought with them, and communicated to the inhabitants of the parts of Germany through which they passed, in 1757, dysentery of a malignant form ; wh ch was entirely similar to the descrip- tion I have given of that variety. It was also prevalent in various other quarters of Germany. Women in the puerpe- ral state, and their infants, were also altacke I. Ipecacuanha, followed by rhubarb, the tartrate of potash, and, lastly, sima- rouba, was chiefly employed. The too early use of astrin- gents, absorbents, and narcotics were said to have been dan- gerous. Isolation of the affected, and lime, as a disinfectant, were resorted to. 26. Dysentery was epidemic, in the autumn of 1760, iu Gottinge'n ; and of an inflammatory and asthenic character, the local inflammatory action being attended by deficient vital power. The excum and rectum were ulcerated and gangrenous. Bleeding, vomits, laxatives, emollients, and antiseptics, with opiates and bark, were principally trusted in (Roederer). 27. According to Grimm, the same epidemic was observ- ed in Thuringen, where it was infectious. A similar treat- ment to that now stated, with the addition of camphor, was adopted. 28. LECLERC describes the dysentery to which the Tar- tars ofthe Ukraine were subject, in consequence of a meagre and indigestible diet, consisting of much salted or smoked fish and meat, and the use of ardent spirits. It seems to have been simply asthenic or malignant; and to have been most successfully treated by ipecacuanha, rhubarb, nitre with camphor, opium, mucilag nous clysters; and, in the lat stage, balsam of tolu, &c. Procidentia ani was cured by conveying to the part the vapour from turpentine thrown upon burning coals. 29. Dysentery succeeded, in July and August, to the catarrh which prevailed in London in 1762; attacked chiefly the poor and children ; and assumed ihe bilious adynamic form. Bleeding, at the beginning, in the more inflammatory cases; emetics and diaphoretics : laxatives and emollient in- jections ; mucilages and astringents, kc, were successively prescribed (G. Baker). 30, This disease also followed catarrh, at Vienna, in the autumn of 1763 (De Mertens) ; and was attributed to cold and moisture consequent upon great heat. Bloodletting was borne by very few. Ipecacuanha, rhubarb, mucilages, and, afterwards, bark, were exhibited. 31. The epidemic in Berne, and adjoin:ng parts, in au- tumn, 1765, was in all respects the same as that which I have denominated the bilious adynamic, according to the ilcscrip- tion of Zimmermann ; who states it to have been infectious in circumstances favouring the action of this property ; and that females, far advanced in pregnancy, in some instances gave birth to infants affected by^it Ipecacuanha emetics, gentle purgatives, diluents and emollients, mucilaginous ene- mata; subsequently, camomile tea and opiates, were chiefly confided in : astringents were injurious. 32. In an epidemic observed, n the same year, by M. Cheyssiol, camphor, blisters, sinapisms, dry-cupping, and cinchona were most beneficial. 33. According to Dr. Sims, the disease was very prevalent in London in the autumn of 1768 ; it having succeeded rheu- matism, and continued during 1769 and 1770. One form proceeded chiefly from cold, was ushered in by rigors, and required bleeding and ipecacuanha < metics. The second and most common form prevailed among those who lived on poor diet. The pulse was low, quick, and unequal; the skin cold; [ the face pale and haggard ; and the stools fcetid and putrid. j In this, ipecacuanha, opium, astringent bitters, bark, aromat- ics, and claret, proved most successful. ' 34. Malignant dysentery was prevalent in Jamaica, in 1771. Dr. Wright found antiseptics, especially a saturated sola- DYSENTERY —Epidemics. 7Q3 turned in upon the bowels. It commonly arises, I sporadically, from cold and moisture — from sup- tion of common salt in lime juice, taken in aromatic or sweetened water, most serviceable. 35. MM. Maret, Durand, and Caile state, tha the epidemic throughout France, in the autumn of 1779, was an illustration- of the aphorism of HIPPOCRATES,—" Hiems sicca et aquilonia, ver autem pluviosum et australe ; necesse est fieri febres acutas et dysentarias maxime,"—and assumed an inflammatory, bilious, and malignant form ; the second and third being very infectious. In many places, children, females, and the aged were principally affected. Blood- letting, which was repeated in some cases ; laxatives, with tamarinds and manna ; mucilages and emollients, in the form of drink and in clysters; camphor and anodynes, lime, and gum-water; cinchona, with camphor and the anodyne liquor, were prescribed according to the form and stage of the disease. 36. BlRNSTIEL records that diarrhoea prevailed, in the spring and summer of 1730, on the Rhine ; and was follow- ed, in autumn, by a violent dysenteric epidemic of a bilious adynamic form — the symptoms being entirely the same, but more intense than I have described them. Evacuations by ipecacuanha and rhubarb, mucilages and diaphoretics, and, towards the close, cascarilla and opium, were confided in. 37. In the years 1785 and 1786, the disease, in simply as thenic and malignant forms i§ 25. 27.). was general through the Venetian states — chiefly in females and children (C apo- VILLa). Fomentations, mucilaginous injections, emollient drinks, ipecacuanha, rhubarb, almond oil, absorbents, and, afterwards cinchona, wine, opiates, and astringents, were most beneficial. 38. The epidemic in Champagne, especially iir the French, Prussian, and Austrian armies, during the autumn of 1792, assumed inflammatory, bilious, malignant, and typhoid forms, according to the causes and circumstances in operation ; and was remarkably fatal among both men and horses (Chamse re.) Bleeding in some ; ipecacuanha, antimouials, emol- lients, cinchona, rhubarb, tamarinds, lemonade, kc, were principally employed. 39. The dysentery that prevailed in the army of Italy (Desgenettes) was rarely inflammatory; but very gene- rally malignant, arising from endemic causes concurring with extreme fatigue and exposure. Aromatics vegetable acids, and opiates; antiseptic and anodyne enemata, cinchona, and imarooba, were most frequently prescribed. 40. HUFELAND states that ft was epidemic at Jena, in 1795, in the simply asthenic and malignant forms. He treat- ed it most successfully by ipecacuanha and extract of nux vomica. It was infectious in favourable circumstances. 41. Schmidtmann states that dysentery was epidemic, through the north of Germany, in 1800; and so prevalent in the town in which he resided, that very few escaped. It as- sumed inflammatory, bilious, nervous, and malignant forms, according to t-ircumstances, and the constitution, &c, of those affected. Bleeding in some cases; gentle emetics in others; opium nearly in all; and camphor, decoction of bark, various astringents, tonics, and antisepiics were em- ployed. Arnica was given in the malignant cases, but w th little benefit; and tamarinds, cream of tartar, manna, or other mild purgatives, were also exhibited. 42. Dysentery, chiefly in the bi ious-inflammatory, passing into the adynamic orm, was remarkably prevalent and fatal, at the Cape of Good Hope, in 1804 (Lichtenstein) ; and was often associated with inflammation and structural cbange of the l.ver. This epidemic was at first very injudiciously treated by stimulants, astringents, ond antispasmodics; and one in four died. The mortality was subsequently reduced one half, b means of small doses of calomel and opium, given every hour or two; sometimes with camphor and rubefacients. 43. This disease was very preva'cnt in Holland, in 1809, particularly in the British troops composing the Walcheren expedition ; and proceeded chiefly from endemic causes, and often either followed or was converted into, intermittent or remittent fever (Davis, Dawson). It was frequently associated with disease ofthe liver and spleen ; and presented the inflammatory, asthenic, and bilious forms. Bleeding, purgatives, calomel, and sudorifics were chiefly employed ; but the disease was too generally injudiciously treated. 44. Dysentery became epidemic, in and around Vienna, in autumn, 1809, particularly in the French army ; and as- sumed, according to circumstances, an inflammatory, bilious, adynamic, typhoid, or malignant form (VlGNEs). It often was infectious; and few of the medical officers escaped. Ipecacuanha, opium, emollients, clysters, sinapisms, and blisters . camphor, ather, arnica serpentaria, cinchona, vale- rian and aromatics, variously combined appear to have been chiefly employed 45. The more simple asthenic states of dysentery were orevalent in Flanders, in July, 1810(Tonnelier); and, in pression of the function of the skin, which is in them a much more important excreting organ than the summer of 1811, in various parts ofthe north of France (Caron). Iu some villages, nearly all the inhabitants were attacked the same day. Ipecacuanha, gentle purgatives, rhubarb, calumba, simarouba, mucilaginous clysters, opiates with diaphoretics, warm baths, arnica, aromatics, Hoff- mann's anodyne, kc, were generally employed. Favour- able changes occurred between the tenth and fifteenth days. The disease sometimes passed into entiritis, and was occa sionally followed by dropsy. 46. Dr. Pisani states, that dysentery of an asthenic kind, but presenting either inflammatory, malignant, or nervous symptoms, was so prevalent in the garrison of Mantua, in 1811 and 1812, thai about 1000 cases were received into the hospital. It first appeared iu some felons; from whom it extended to the -oldiers in the wards, and by them was con- veyed into the barracks. The medical attendants and assist- ants were attacked; but those who had no communication with the sick escaped. Small depletions, ipecacuanha, lax- atives, emollients: with nitre, fomentations, mucilaginous clysters, neutral salts, rhubarb, Hoffmann's anodyne, cam- phor, and wine, according to the features of (he disease, were most employed. Ventilations and fumigations were also resorted to. 47. In the expedition to New Orleans, dysentery, owing to cold, moist, and miasmalous ai , wet clothing, and the use of foul brackish water, and fatigue, was the most fatal disease, assuming inflammatory, bilious, asthenic, and malignant forms. Bleeding, emollients, fomentations, opium, Dover's powder, and very large doses of calomel, appear to have been principally confided in. In fatal cases, the liver was frequently found diseased ; and the colon very slightly ulce- rated, but not sphacelated.—(Edin. Med. Journ. vol. xii. p. 136.1 43. Dysentery, although it may not be said to have been epidemi in the strict sense of the word, was the most fatal disease in the British army during the Peninsular war. It was often connected with inlermittenls and remittents, and frequently supervened on these and other forms of fever (Sir J. M'Grigor) ; and attacked convalescents. It assum- ed inflammatory, bilious, typhoid, or malignant and chronic forms, according to the causes and concurrent circumstances. It was most prevalent and fatal at Ciudad Rodrigo, which was obliged to be made an hospital station for a time ; and where, snortly before, "near y 20,000 bodies were calculat- ed to have been put into the earth, either in the town or under its walls, in a few months." It was unhealthy, inde- pendently of this circumstance. It was commonlv treated by venesection, in the first stage ; and by the warm bath, full doses of Dover's powder every hour, ca omrel and opium at night, sulphate of magnesia, in broth, in the morning : in the second stage, by demulcents, aromatics, opium, astringents, tonics, and flannel rollers. 49. This disease has been more or less prevalent in- some part or other of Ireland, owing to the presence of endemic and even of epidemic causes. During 1817. 1818, and 1819, it was,conjointly with fever epidemic throughout the island. The seasons were cold and wet; and, with this cause, famine, unwholesome food, and infection concurred. It was very often consequent upon the early stage of fever, or it appear- ed as a crisis of fever, or it occurred during convalescence. It wa, infectious in circumstances favouring this properly ; and presented inflammatory characters, but often associated with the asthenic diathesis. It was treated chiefly by mod- erate bleeding, ipecacuanha, the warm bath, opium in doses of four or five grains, calomel with opium, copaivi mixture, and farinaceous diet (Cheyne). 50. It was prevalent in several parts of Ireland, in 1722, at the same . line with low fever, owing to scanty and bad food. It commenced with debility, pain about the umbili- cus, mucous dejections general cachexia, rapid and weak pulse, &c. ; on which the pathognomonic symptoms super- vened in an adynamic form. It was very fatal until whole- some and nutritious food was obtained (Dr. Graves, in Trans, of Irish Col. of Phys. vol. iv. p. 429/) 51. It was again prevalent in Dublin and the vicinity, in ihe autumn of 1825 after great heat and drought: affected first the better classes; somet mes appeared as fever for two or three days, and then passed into dysentery ; or it occurred during convalescence from fever, and was infectious (Dr. O'Brien). It was of an asthenic and complicated form ; the skin being of a dirty or dark hue, and harsh to the touch ; and was very generally treated by bleeding, in robust per- sons, at an early stage; by the warm bath, and friction of the surface witn camphorated oil; by calomel gr. x., and opium gr. ij., repeated in eight hours, and follow d by pur- gatives, especially castor oil with a few drops of laudanum , by flannel rollers around the abdomen; and by Dover's powder, and the repetition of one or more of these means, according to circumstances. 704 DYSENTERY — Its Type. in the white races; from insufficient and unwhole- some food; and, endemically, from bad water, marsh effluvia, and animal and vegetable emana- tions floating in a moist atmosphere. It assumes some one ofthe asthenic forms, according to the causes which produce it, and the circumstances which influence it in its progress. Even when it appears sporadically, it is more liable to become infectious than in Europeans, owing to its passing more readily into a low, malignant, or putrid form, on occasions of imperfect ventilation or crowding of the sick. In such circumstances, it is sometimes quite pestilential in the rapidity of its dissemination and the extent of its fatality. In its sporadic states, it is frequently assodated with rheumatism, or the one passes into the other; both generally arising from the same exciting causes - - from cold and moisture. It is also very often complicated with worms, especially the round worm, in the prima via ; these being passed with the stools in the advanced stage of the more severe and danger- ous cases; and, in its less severe grades, it some- times assumes intermittent or remittent types. 31. When dysentery attacks the dark races sporadically, and sometimes, when it seizes Euro- peans who have resided very long in a warm climate, it frequently commences with chills and much febrile reaction or irritation, the vascular excitement rapidly passing into an adynamic state — into great prostration of the vital and animal actions, and depression of spirits. The pulse is, at first, more or less quick and irritable — some- times sharp and full ; but it always becomes, in the space of one, two, or three days, small and soft. The rapidity ofthe change is seldom owing either to the loss of blood from the bowels, or to the quantity of matters evacuated, but rather to these conjoined with the exhaustion produced by the causes of the complaint, by the severity of the tormina, the want of sleep, and by the febrile irri- tation ofthe system, in less vigorous constitutions than those of the white race. In this class of pa- tients, flatulence, nausea, sometimes porracious or bilious vomiting, quick small pulse, and occasion- ally scybalous evacuations, often containing worms, 52. The disease was epidemic, in some parts of France, in the autumn and winter of 1825 (MM. Denoyer, Lemer- C1ER, and Bienvenu) ; and was, in several places, propa- gated by the exhalations from the sick and the evacuations; children, females, the weak, ill fed, the aged, and those liv- ing near unhealthy and moist localities, being chiefly attack- ed. It assumed inflammatory, asthenic, and malignant forms; and. in several places, the small intestines and stomach were also affected. It was treated chiefly by local depletions, opium, repeated application of blisters, and demulcents. Tonics and antiseptics were required in the advanced stages and chronic Hates. 53. It again prevailed, in some parts of that kingdom, in October, 1827; and was, in several localities, attributed to the water, which abounded with decayed animal and vege- table matters, animalcule, kc (M. Compaqny). It pre- sented either inflammatory, mucous, asthenic, and malignant characters; and was treated by leeches, opiates, demulcents, and, afterwards, by camphor and cinchona. 54. The disease was epidemic in Glasgow, in the autumn of 1827 in a simply asthenic and mild form. Opiates, calo- mel and opium, ipecacuanha, demulcent enemata, blisters, warm baths, astringents, and bitter tonics were most service- able. Bleeding, unless by leeches, was very seldom required, and was often injurious (Wilson, Brown, and Macfak- lane). 55. Infectious dysentery, in adynamic or typhoid forms, has frequently appeared in ships, in prisons, and wherever many persons have been collected in ill-ventilated, and par- ticularly in moist and miasmatous, situations. Instances of such occurrences are so numerous, have been so often notic- ed, and are so well known, that it is unnecessary to refer to them are very early observed; the surface of the body being shrunk, the superficial veins deprived of blood, and the extremities moistened by a colli- quative sweat. In these persons, however inflam* inatory the disease may be at its commencement, it soon exhausts vital power, and passes into the asthenic form ; and, in seasoned Europeans, is sometimes contingent on, and complicated with, disease ofthe liver, or ofthe spleen, or even often ofthe absorbent glands; or is consequent on fevers, both periodic and continued, either in their course, or during convalescence from them. 32. III. Of the Type of Dysentery.— The inflammatory typhoid, and more malignant forms of the disease, are generally continued, or obscurely remittent. But the other forms may as- sume an obviously remittent, or even an intermit- tent type, owing rather to the concurrence of those causes to which periodicity in fever is owing, with those on which the dysenteric phenomena are more immediately dependent, than to the produc- tion of two distinct kinds of disease. We have seen, that dysentery often arises from endemic causes, very nearly similar to those which produce periodic fevers ; the causes of the latter chiefly impressing the nervous system, those of the former vitiating the secreted and circulating fluids, und disordering the functions ofthe bowels. Therefore, when both kinds of causes concur, as they fre- quently do, in unhealthy situations and seasons, u form of disease is directly produced, in which many ofthe characters of both disorders are blend- ed. In such cases, the ingestion of foul water, or of unwholesome food, and cold and moisture, con- taminate the fluids, determine them to, and irritate, the prima via ; whilst malaria, concurring with these causes, impresses the nervous system so as to impart a certain degree of periodicity to the morbid actions resulting from the combined agents. It also not unfrequently occurs, that, during the progress of agues and remittents, the secretions accumulated in, or poured into, the intestines will acquire such irritating or morbid properties as to superinduce dysentery, which will often for awhile retain the periodic character; but, in most instanc- es, a continued or obscurely remittent type will be the consequence of this change. A distinctly inter- mitting type is incompatible with either a consid- erable extent of inflammation, or much deprava- tion of the circulating fluid; and one or other, or even both, of these changes, obtains in those forms of this disease which I have stated to be generally exempt from this character. It is frequently ob- served, that, when animal or infectious emanations enter largely into the causes of this disease, it as- sumes a continued and more or less of a malignant character. Numerous instances, illustrative of these views, came before me in warm climates : and the histories of the epidemic occurrences of the disease, when examined in their details, further confirm them. Sir J. M'Grigor, in his excel- lent review of the diseases of the army during the Peninsular war, states, that, in the hospitals in the Alemtejo and Estremadura, the type of dysentery was intermittent; that it became remittent in July, August, and September, when the army advanced rapidly, and remained some time stationary in the two Castiles; and that it was continued, typhoid, and very fatal, at Ciudad Rodrigo, where the sick were exposed to the effluvium extricated by 20,000 dead bodies. Here we see the disease pre- DYSENTERY — Its Complications —Hepatic. 705 tenting increased grades of severity as the causes augmented in intensity. 3:5. IV. Complications.—Having considered the forms of dysentery depending more directly upon the nature ofthe predisposing, exciting, and concurrent causes, I now proceed to notice those complications occasionally observed, especially in unhealthy seasons and localities. Many writers conceive that the asthenic varieties described above are complications of simple dysentery with different kinds of fever; and that, when they are infec- tious, it is not the dysentery but the fever which possesses this property. Some authors suppose that the typhoid variety especially is a compli- cation of this description. But, if such be the case, wherefore should the disorder which is com- municated be always dysentery and not fever ? Moreover, this form of dysentery is often present where a case of typhus cannot be found. The fact is incontrovertible, that the asthenic forms, some of which are considered as complications by many writers, are direct, and necessary, and uni- form results of certain diversified but concurrent causes; and not contingent associations of two diseases capable of separate existences, such as those about to be described : thus, cold and mois- ture will of themselves sometimes occasion simple inflammatory dysentery — as frequently occurs, where no other causes can be in operation; but when, with cold and moisture, there concur mal- aria, unwholesome food or water, or emanations contaminating the fluids, as is often the case, the disease assumes some one ofthe more severe and asthenic forms; the nervous and circulating func- tions having been thereby more seriously im- pressed. The local affection is occasioned, in these cases, by the nature of the ingesta, or by the morbid secretions consequent upon the action of the exciting causes, or by the retention of morbid or fiscal matters, or by two or all of these com- bined. (See § 70—72.) The complications of which more particular notice will be here taken are most commonly occasioned by the endemic causes of dysentery, and are those—(a) with diseases ofthe liver, spleen, and some other abdominal viscera; —(b) with jaundice;—(c) with scurvy, or scor- butic dysentery;—(d) with worms in the prima via;—(e) with haemorrhoids;—and (/) with rheumatism. 34. A. Dysentery complicated with Disease of the Liver, Spleen, fyc.—Hepatic Dysentery of writers on intertropical diseases.—(a) I have al- ready noticed an asthenic form in which the bile is excreted more or less in excess, or is otherwise dis- ordered. In this form, which is frequently epi- demic, there has generally taken place, for some time previously, an accumulation of this fluid in the biliary apparatus, without any actual disease ofthe liver; the discharge of much altered or acrid bile contributing, probably, with other morbid secre- tions and actions, to the production or perpetuation of the dysenteric symptoms. But, in the complica- tion now about to be considered, the liver is gener- ally inflamed, enlarged, or otherwise altered in structure, either previously to, coetaneously with, or consecutively on, the dysenteric affection. Al- though this association of diseases of distinct but related organs is most frequent in the sub-acute and chronic states, it sometimes also occurs in any of the acute forms, as well in temperate as in warm climates; but oftener in the latter than in [ the former. It is also consequent upon agues, remittents, and continued fevers; and it is evi- dently often produced by endemic causes, es- pecially in persons addicted to ardent spirits. When hepatic dysentery proceeds from these causes, the spleen is sometimes also diseased, as well as the pancreas, and mesenteric glands. Sir J. M'Grigor states, that, in the fatal cases of dysentery that occurred in the Peninsula, the spleen was as often diseased as the liver; and that both the pancreas and mesenteric glands were also frequently enlarged or otherwise changed. When acute dysentery is complicated with disease of the liver, this latter is frequently, likewise, of an acute or sub-acute character; and consists chiefly of in- flammation of the substance of the organ; abscess and the chronic changes of this viscus being more commonly associated with sub-acute and chronic dysentery than with the acute. 35. «. Acute hepatic Dysentery generally com- mences with horripilations, chills or rigors, fol- lowed by pains in the forehead; bilious vomiting; bilious and variously coloured stools, voided with scalding at the anus, and urgent tenesmus. The discharges are often at first greenish, greenish black, or reddish brown and ochre-like; or watery, with a greenish frothy slime on the surface. A fixed pain, weight, or uneasiness, increased on pressure, is generally felt in the epigastrium, fre- quently extending to the right hypochondrium, right scapula, or top of the right shoulder; with a sense of pressure or tension in the right side of the thorax, anxiety at the praecordia, fits of dys- pnoea, or a dry teasing cough, vertigo, and an accelerated and irritable pulse, particularly at night, when the patient becomes very restless, and the calls to stool more frequent and distressing. The tongue is at first white, the papillae erect, or covered by a yellowish fur. At an advanced stage, it is clean, dry, smooth, red, or lobulated; or it is covered at the root with a dark crust. The skin is dry, harsh, of a dirty appearance, and hot; or it is covered by a greasy perspiration, copious sweats sometimes occurring in the last stage of the malady. There is great thirst, and desire of cold fluids. In other respects, the progress of the disease is similar to the more inflammatory form described above (§ 13.); but it often presents a greater range of symptoms in different cases, or at different stages of the same case. 36. p. In the above form of hepatic dysentery, the affections of the large bowels and liver seem to be nearly coetaneous; but, more frequently, the hepatic disease follows dysentery, or does not appear until this latter begins to decline. In these cases, the patient is irritable, the cheeks present a hectic flush, and, upon examining the abdomen, the right rectus abdominis muscle resists pressure by an involuntary action. Little or no enlargement ofthe organ is at first felt; but either enlargement or tenderness becomes manifest, es- pecially when blood has entirely disappeared from the stools, which are generally scanty, viscid, and dark. This form of the complication is evidently caused by the sudden cessation of the dysenteric affections; which, being very intimately dependent upon the excretion of morbid matters from the circulation and the economy in general, cannot be abruptly suppressed, without inducing continued or remittent fever, or inflammation, congestion, or en largement of excreting organs. Both these mo- 706 DYSENTERY —Its Com plications — Scorbutic. difications of hepatic dysentery are often attended by much pain about the umbilicus, by irritability of stomach, and other indications of severe asso- ciated disease of the internal surface of the small intestines, and even of the stomach; particularly in warm climates, or in hot seasons when dysen- tery is epidemic, and in persons addicted to spirit- uous liquors. In some cases of hepatic dysentery, the liver is the only viscus, besides the large bowels, which is diseased; but, in many, the spleen, or the pancreas, and the mesenteric glands, are also affected. 37. (6)The complication with enlargement, thick- ening of the envelopes, or softening or other dis- orders, of the spleen, is of frequent occurrence where dysentery depends chiefly upon endemic causes, and when it is consequent upon agues or re- mittents. Thus, in places abounding with malaria, the splenic association of dysentery is much more frequent, especially among the natives of India, than the hepatic; the pancreas and lacteal glands being often also changed, and the disease assuming an intermittent or remittent type. Like the he- patic, the splenic affection may precede, may be coetaneous with, or consequent upon, the bowel disease; but it is a more common result, par- ticularly when the dysentery presents a periodic type, ofthe suppression ofthe discharges by means of astringents, before evacuants have been carried sufficiently far, or morbid matters evacuated. Thus I have seen dysentery consequent upon ague or remittents, when abruptly suppressed, to have been followed by a return of these forms of fever, and by enlargement of the spleen, in localities abounding with malaria; and nearly similar occur- rences appear, from the comprehensive account furnished by Sir J. M'Grigor, to have been ob- served in the peninsular war. In this complication, the symptoms are but little different fiotn the simple states of dysentery above described; but they more frequently assume a sub-acute and chronic, than an acute, form. In the cases that have come before me, the splenic affection could seldom be detected unless it consisted chiefly of enlargement, when a careful examination readily disclosed the state of disorder. In all endemic maladies, where we suspect disease ofthe spleen, the examination should be made with caution, as this organ may be most seriously injured by rough- ness. In some cases, as well, indeed, as in those in which the pancreas and mesenteric glands have been enlarged, the countenance and skin have presented a dirty or leaden hue, and the limbs have been much emaciated. But these compli- cations are more common in chronic dysentery. 38. B. Jaundice is sometimes observed asso- ciated with dysentery, especially when the liver is diseased. But it may occur without auy struc- tural change of this viscus, owing to obstruction of the ducts, or to occlusion of the orifice of the common duct by inflammatory tumefaction ofthe mucous surface of the duodenum. It may pos- sibly also arise from the absorption of morbid bile from the intestinal canal; or from the state ofthe soft solids themselves; these having acquired during disease the power of separating the colour- ing principles of the bile from the blood. (See Disease, § 108., and Jaundice.) 39. C With Scurvy, or Scorbutic Dysentery.— This complication of dysentery was formerly much more frequent than at the present day; particularly in ships on long voyages, before lime juice was introduced as an antiscorbutic. When, however, the particular concurrence of causes whence it proceeds takes place, and is not counteracted by appropriate means, v!e must ex- pect this form of the disease to prevail. Its de- structive prevalence among the troops — British and native — employed in the Burmese war; and its occurrence in a modified form in the Peniten- tiary at Milbank; prove this position. On- occa- sions of long navigation, and the transport of troops; in campaigns, sieges, or active military services, when there is a scarcity of fresh and wholesome provisions, with the usual causes of dysentery; this complication sometimes presents itself at the same time as the more malignant states of the disease; and in such circumstances, it is occasionally the prevailing and most destructive form. 40. a. The Causes which usually give rise to the disease are generally the concurrence, or subse- quent operation, of those which produce dysentery, with such as occasion, or have already occasioned, scurvy,—especially living long on salted provi- sions, particularly pork, without a due supply of vegetables or farinaceous substances; innutritious, deficient, or unwholesome food, or the prolonged use of a fluid and greatly diluted diet; debility from previous disease; excessive fatigue; stagnant and foul water; concentrated marshy exhalations, or night-fogs in low situations and places border- ing on the sea, or banks of rivers or lakes; confine- ment, or want of exercise in the open air and in the light of day, especially in miasmatous localities; nostalgia; anxiety of mind, disappointments, and depression of spirits; and, in some circumstances, particularly in the natives of warm climates, an insufficient supply of salt, or of warm spices and aromatics; or living on a poor, watery, and vegeta- ble diet. Persons who have had dysentery, are very liable to this complication when subjected to the causes of scurvy. These causes lower the ner- vous and vital power, contaminate the circulating and secreted fluids, and ultimately deteriorate the vital properties of the soft solids; favouring serous or sanious exudations from the mucous surfaces, and those capillaries which derive the least support from the cohesion or density of the tissues they supply. Hence result the phenomena of this complication, when the weakened bowels are ir- ritated by the morbid secretions poured into them from the collatitious viscera, and from their own glands and mucous surface; or by injurious in- gesta. 41. b. Symptoms. — In this complication, very evident signs of scorbutic cachexia generally pre- cede, for a longer or shorter time, the dysenteric symptoms, which, when they are developed, re- semble the malignant variety above described (§ 27.), excepting that they are not attended by any febrile commotion; the antecedent conta- mination ofthe system being much more manifest than in the variety referred to, and symptoms indicating increased vascular action being usually absent: the countenance is pale, heavy, dark, de- jected; in some cases sunk, in others slightly cede- matous; the abdomen is drawn inwards, or sore upon pressure; the lower extremities are cedema- tous, with livid patches extending to the hams, fre- quently with ecchymoses,or petechue,or the break- ing out of old ulcers, and with coldness of the sur- DYSENTERY face. The gums are spongy, dark, livid, tumid, and bleed upon the slightest pressure; the tongue is flabby, often raw,red,or reddish brown. The pulse is small, weak, and soft; and afterwards quick, feeble, and undulating. Sometimes, nearly coeta- neously with the above appearances, but more fre- quently after they have commenced and proceeded some length, diarrhoea occurs. The evacuations soon assume a serous or sanious appearance, with mucus, and grumous dark blood, mixed with fe- culent matters; and they are usually accompanied by griping and tenesmus, but in a much less de- gree than in the more simple forms of dysentery. Faecal matters are seldom retained, the stools being free and sometimes copious. The biliary secretion is often more or less disordered; it being either copious or morbid—and then it increases the ex- coriation of the intestinal mucous surface; or di- minished, or altogether obstructed. The urine is scanty, of a dark muddy appearance, or sanguine- ous; and a peculiar foetor is often exhaled from both the alvine and cutaneous excretions. In the more severe cases, or towards the close, there is occasionally vomiting of a bilious, bloody, or dark and grumous fluid, with distressing flatulence, and pain or soreness in the hypochondria. The func- tions of the stomach are generally disturbed; and there is much disrelish of salted meat,or ofthe food on which the patient has been subsisting, with great desire for vegetable acids, vegetables, fruits, warm spices, fresh meat, milk, &c. In the pro- gress ofthe more dangerous cases, copious effusions of fluid dark blood, with detached portions of the mucous surface, are seen in the dejections; with coldness and lividity of the surface, leipothymia, and sometimes with paralysis of the sphincter ani, and excoriations about the anus. Discolouration of the surface, breaking out of old sores, falling out of the teeth, great loss of flesh and prostration of strength, and extreme despondency, further characterise the advanced stage. 42. D. Dysentery is ro frequently complicated with Worms in the prima via, that many writers consider them to predispose to it; and with much probability. The large round worm is the spe- cies most frequently observed; but others are occasionally seen. The excretion of worms has been viewed by many as an unfavourable symp- tom; and I believe that it often is so, as it indi- cates a grave affection of the system, or the ex- tension of disease to the small intestines. When dysentery is prevalent among the inhabitants of unhealthy localities, or the natives of hot climates, this complication is observed in a large proportion, sometimes in more than one half, of those attack- ed; and, in the latter class of subjects especially, it is characterised by more or loss asthenia, and assumes some one of the forms arranged under this head, according to the nature of the exciting and concurrent causes. 43. E. The disease may also occur in a person liable to, or affected by, Hamorrhoids; especially in those of a plethoric or sanguine constitution, or who are subject to vascular determination to the prostate gland and rectum, from too frequent sexual congress. In such cases, the tenesmus is often the chief symptom; and, in consequence of the tumefaction of the vessels, and coats of the rectum, a complete retention of faecal matters and constant straining are present. The disorder is commonly local, chiefly simple,and inflammatory, I, CHRONIC. 707 and often subsides upon a copious discharge of blood from the internal hcemorrhoidal vessels, which takes place after longer or shorter suffering, and frequently oftener than once. In some cases, prolapsus ani occur-i, and aggravates the symp- toms. In other respects, this complication differs but little from the mild or inflammatory forms (§ 12.) described above. 44. F. The assodation of Rheumatic Symptoms with Dysentery has been so frequently observed, that many authors (§ 74.?.) have contended for the rheumatic nature ofthe disease. The connection of rheumatism with dysentery occurs in one or other of the following ways:—1. Rheumatism may be prevalent either before, or at the same time as, or subsequently to, dysentery :— 2. It may also precede, accompany, or follow, the bowel disease in the same person. In all these forms the connection has been observed by au- thors, and in some of them by myself, — but chiefly in the slighter or more inflammatory forms, which are most frequently occasioned by the same causes as those which produce rheumatism, viz. cold and moisture, or vicissitudes of tempe- rature, with terrestrial emanations: dysentery at- tacking those who are predisposed to it by the accumulation and stagnation of morbid secretions or acrid faecal, matters in the digestive viscera, &c.; and rheumatism, those who possess the rheu- matic diathesis, or in whom the morbid secretions are not set loose, or the balance of circulation and exhalation is not thrown in upon the intestinal canal. Conformably with this view, it will be evident that both affections may occasionally co- exist, and that either may supervene upon the disappearance of the other, especially when the above causes continue in operation. 45. V. Sub-acute and Chronic Dysente- ry, and Chronic Diarrhea.—i. Dysentery may occur primarily in the mild and sub-acute form described above (§ 12.); and yet, in conse- quence of neglect, or of the continued exposure of the patient to its endemic or other causes, it may run on to a very chronic duration, or assume the form of chronic diarrhcea or lientery. It may lapse into either of these forms from the acute, in a grad- ual manner; or either of them may commence as diarrhoea; the characters of sub-acute or chronic dysentery appearing gradually, or more or less sud- denly, in their progress. When the disease arises chiefly from malaria or other endemic causes; or follows agues, remittents, and diseases ofthe liver or spleen; it more generally assumes a sub-acute and chronic form, or passes into chronic diarrhoea, than in other circumstances. In other respects, the causes of the chronic states of dysentery, even when occurring: primarily, are the same as those that produce the acute forms. These states, how- ever, are oftener met with in those who have had disorders ofthe stomach, liver, or bowels, in long residents in warm climates or unhealthy localities, and in the natives of such places, than in others; and they are more frequently complicated with diseases of the liver, spleen, omentum, pancreas, &c. in persons thus circumstanced. In most cases, these states of the disease differ from the acute, chiefly in the greater mildness ofthe symp- toms, in the absence of a few ofthe more violent phenomena, and in the much more uncontrollable and persistent nature of such as are present. Be- sides following upon, or being rather prolongations 703 DYSENTERY, CHRONIC—Complications of. of, the acute, they may be the sequelae of any of I voided with tenesmus, but without tormina, the the forms of diarrhoea, of common or pestilential | rectum only is affected; one or more ulcers cholera, and of fevers that have been neglected in being seated at a greater or less distance from their early stages, or improperly treated. When the anus. The sub-acute and chronic forms are it occurs primarily, which is comparatively rare, not infrequent in children, are in them often ac- it may, after a considerable time, assume the companied by proddentia ani, and are generally acute characters. inflammatory, particularly when occurring spora- 46. a. The Symptoms of chronic dysentery | dically. Chronic dysentery in the dark races differ chiefly in degree from those characterising I assumes the appearance of a gleety discharge the more simple inflammatory form of the acute ( from the bowels, and depends upon deficient disease (§ 12, 13.). The fever of the latter gen- \ tone of the vessels and follicles of the intestinal erally subsides, especially during the day; and the I mucous surface, rather than upon inflammatory appetite and strength frequently return for a time, action. Tormina and tenesmus either altogether disappear, \ 48. ii. Complications of Chronic Dysentery are or are present in a slight degree; but sharp griping ) most frequent in countries within the tropics, and in pains, and soreness in the abdomen, are often com- I places abounding with terrestrial emanations.— plained of. The stools are more or less serous, mu- I (a) When chronic dysentery is complicated with cous, muco-puriform, or gelatinous; contain some I disease ofthe liver, the symptoms often approach fluid feculent matter, or ill-digested substances; those of diarrhoea; and the hepatic affection and vary from a white albuminous, or white of egg, I is generally latent, insidious, and also chronic ; appearance, to a dark olive green or greenish the internal structure of the organ being chiefly black; being sometimes marbled; or one day ' implicated. In this state of disease, the evacu- like chalk and water, and on another like a | ations are frequent; attended by griping pains dark jelly, or the green fat of a turtle. Blood i about the umbilicus; and are of a dark green is often either so intimately mixed with the eva- ' colour, indicating a morbid state of the bile; or cuation as to give it an uniform brick-red colour, of a pale clay colour, showing torpor of the or is quite distinct and fluid, or partially coagulated, liver or obstruction of the ducts. In some cases, The puriform or muco-puriform matter generally they are dirty, watery, and offensive; and in exists as small streaks; but this matter may not others, of a whitish appearance.: whence has be detected, although ulceration of the large arisen the term " white flux." These last seem bowels is present. The discharges are more I like chalk or lime mixed in a dirty fluid, or inter- copious than in acute dysentery, but much less mediate between this and whites of eggs; occas- frequent; being commonly from three or four to j ionally they resemble cream or yeast; and they are ten or twelve in the twenty-four hours. The | often slimy, and contain broken down, clay- pulse i4 not accelerated in the early part of the coloured faeces, and half-digested substances. day, but it usually becomes quicker towards eve- These sometimes continue for a longtime; or they ning; and is feeble, unequal, sometimes slow, or change to a darker colour, apparently from a par- intermitting. The tongue is often dark red or ■ tial discharge of bile or the medicines taken; and glossy; the countenance sunk and anxious; the afterwards return to their former hue. This state surface cold, lurid, dirty, harsh, dry, or even ofthe dejection is evidently owing to the obstruc- scaly; the body emaciated; and the abdomen tion of bile, to the consequent impairment of hard, tumid, not very painful on pressure, ex- chylifaction, and to the increased and morbid cepting about the caecum or sigmoid flexure of secretion of the follicular glands and mucous the colon, with griping pains in the course of the surface. In addition to these, the patient corn- colon. In the more advanced stages of the dis- plains of tightness, fulness, or oppression at the ease, the feet and legs become cedematous; the epigastrium and lower part of the thorax, par- lips and surface exsanguineous; the surface and ticularly on the right side; and of slight evening the evacuations exhale a peculiar, offensive, and exacerbations of fever. The eyes have frequently sub-acid odour; sometimes jaundice or ascites su- > a pearly appearance; and the countenance is pervenes, and the patient at last sinks under the livid or sallow. This complication is often caused irritation and hectic symptoms, after many weeks by the excessive use of spirituous and other or even months of continued or remittent suf- intoxicating liquors; and by the concurrence of fering. I the causes of hepatitis with those of dysentery; 47. p. Chronic dysentery sometimes assumes and it frequently is consequent upon hepatitis; a modified character, which is essentially the upon intermittent, remittent, or continued fevers; same as the ulcerated and lienteric forms of J and upon the acute disease, when it arises from Diarrhea (§ 11, 12.). In these cases, the endemic causes. The dysenteric symptoms are mucous follicles and coat of the small, as well as manifestly occasioned or perpetuated either by a of the large, intestines are affected; but in warm morbid condition, or by deficiency, or total ob- climates and unhealthy situations, disease extends struction, of bile : this secretion being indispen- much further, and generally comprises lesions sable to the due performance of the assimilating either of the liver, spleen, pancreas, mesenteric processes, and to the healthy state of the mucous glands, or of two or more of these. Repeated surfaces and follicles. In other cases of this attacks of dysentery, in these places, frequently complication, the enlargement of the liver, or the terminate in chronic dysenteric diarrhoea in a symptoms of hepatic disease, are less equivocal, simple or complicated state; and I have seen and approach more nearly those stated above cases where it has continued for years, with slight (§ 35.). (See, also, Liver .— Abscess in.) remissions ; the stools being lienteric, copious, ' 49. (6)—u. When chronic dysentery follows and crude, and the appetite ravenous. In some the diseases just now mentioned, or the prolonged cases of this protracted state of disease, espe- or intense operation of endemic causes, it may cially where the stools are gleety or mucous, and become associated with scorbutic symptoms; or DYSENTERY—Terminations and Prognosis of. 7Q9 dysentery, in a sub-acute or chronic form, may I be consequent upon scurvy, as in the scorbutic complication already described (§ 39.). The chronic states of the disease may also asso- ciate with them changes of other viscera beside those of the liver. In the hepatic complication, especially in hot countries, the internal surface of the small intestines is very frequently also in- flamed or ulcerated, and the spleen, pancreas, mesenteric glandi, or omentum, may be affected in addition. When chronic dysentery follows periodic fevers, the spleen and mesenteric glands seldom are altogether sound. I have never wit- nessed an inspection of a case, either in temperate or in warm climates, that did not present lesions in one or more of these organs, beside those in the bowels; but some of these were manifestly consequences of the disease, and not associated with its early stages. With the exception of the complications with disease of the liver and spleen, the exact pathological state can seldom be ascer- tained during life. When the patient is very much emaciated, enlargement of the pancreas or of the mesenteric glands may be suspected, from hardness and fulness in the abdomen—usually between the pit of the stomach and umbilicus; and from aching pains in the back. — p. In the dark races, the complication of chronic dysentery or diarrhoea with disease of the liver is very rare; but those with enlargement of the spleen and of the mesenteric glands, with ivorms, and with rheumatism, —especially the last two, — are very common.— •/. In children, the association of the complaint with enlargement of the mesenteric glands, or with worms, Ls not infrequent; and the complication of the slighter or sub-acute states with bronchitis is sometimes also met with among them. 50. VI. Terminations and Prognosis.—i. The Acute varieties ofthe disease may terminate— 1st, in a return to health;—2d, in periodic or con- tinued fever, or some visceral disease;—3d, in ulce- ration, and the extension of inflammatory action to the peritoneum, or perforation ofthe bowels;—4th, in sloughing of the internal tunics, and gangrene of portions of the intestinal tissues;—and, 5th, after having assumed a chronic form, in constriction of the colon, and other organic lesions; or in gradual exhaustion of the powers of the constitution.— (a) A favourable issue may be expected, if the stools become less frequent, more copious and feculent, and the biliary secretion more natural; if the tormina and tenesmus abate, and the patient be less disturbed in the night; if the abdomen be less painful, especially on pressure; and if tume- faction or tension be not present; if the febrile phenomena be alleviated, the pulse, tongue, and skin becoming more natural, between the sixth and seventeenth days in the asthenic forms; and if the symptoms indicating the other terminations be not observed. 51. (b) When the disease is suddenly arrested by astringents, or otherwise injudiciously treated, particularly when it arises from endemic and epi- demic causes, it may pass into ague, remittent or continued fever; or into inflammation and abscess ofthe liver, or into peritonitis or enteritis. These results evidently arise from the stoppage ofthe dis- charge of morbid matters that require elimination from the system, and the consequent irritation these matters produce upon the nervous and circulating | systems, or upon the organs chiefly concerned in excreting them. But, on some occasions, these maladies may supervene, without any aid from the practitioner. When dysentery occurs in the puerperal state, particularly soon after delivery (and, when the disease is epidemic, females thus circumstanced are very liable to it), it is very apt to pass into peritonitis; or to be followed by effusion into the peritoneum, and even by inflam- mation of the womb. In 1832, I treated a case of sporadic dysentery in a lady who had not been pregnant for several years. It was followed by hysteritis; which, in its turn, was followed by phlegmasia dolens, first in one thigh, and then in the other. She is now in good health. In some instances, particularly in hot climates and in young children, introsusception of portions ofthe intestines may take place, and give rise to grumous or feculent vomitings, and all the symptoms of ileus. I have sometimes seen children seized, during dysenteric complaints, with convulsions, obstinate vomiting, distressing colicky pains in the abdomen, and stupor, followed by various sympa- thetic phenomena, and death; and, upon dissec- tion, the only lesion, besides signs of irritation in the digestive mucous surface, has been invagi- nation of more or less of the intestinal tube, and the usual consequences of this occurrence. In a case of this kind, which was supposed to have died of acute hydrocephalus by the medical attendant, and which was opened by Mr. Alcock in my presence, the greater part of the ilium had passed into the caecum; and the caecum, with its contents, into the transverse arch of the colon. 52. (c) If a favourable change take not place, in the more sthenic varieties, before the twenty- fourth day; and in the asthenic states, previously to the eighteenth or nineteenth days; or if only a partial change be observed; the disease usually either passes into the chronic form, or assumes still more severe characters. 53. (d) An unfavourable termination may be looked for, iftheforegoingsymptoms (§50.) be ag- gravated; or if no impression have been made upon the complaint, about the time stated above; or be- tween the ninth and fourteenth days in the severe asthenic forms; if the abdomen become enlarged, tense, or tender, or preternaturally hot, especially about the umbilicus; or if pain increase rapidly, and be constant and fixed in one part; if the watery discharges, loss of blood, or the harassing fre- quency of the calls to stool, particularly at night, sink the powers of life, or be attended by cramps in the lower extremities, leipothymia, or syncope; if the face be anxious, or Hippocratic, and the body emaciated; if stupor, delirium, picking of the bed-clothes, startings of the tendons, super vene; if the extremities or surface be discoloured, or the former be cold or clammy, or the latter of a lurid hue, or exhale a cadaverous or an offensive odour; if drinking be followed by tormina and a desire to go to stool; if the tongue be raw, glossy, or very dry, and dark red; or dark sordes collect about the teeth, or aphtha- appear in the mouth or on the lips; if the pulse be very weak, irregular, or intermittent, or rise in frequency to upwards of 120; if respiration be rapid, laboured, or difficult; if the breath be fcetid and cold; if the matters vomited be offensive or grumous; if ecchynioses or sphacelating ulcers appear on the surface; if sight or hearing be partially lost; if paralysis of 710 DYSENTERY —Morbid Appearances. the sphincter ani take place, and the stools be involuntary, or grumous, or like washings of meat, cadaverous, or mixed with small black coagula, or with light muco-puriform streaks, and especially if they contain sphacelated portions of the mucous coat; if the stomach be so irritable as to reject whatever is taken; and if complete strangury or suppression of urine take place. Hiccup is not an unfavourable symptom, if it occur early in the disease: but when it comes on at an advanced stage, it is often an indication of the extension ofthe disease to the peritoneum, or of the sphacelation of the mucous membrane. 54. a. Ulceration may take place early, even in the mildest forms of the disease, without causing any decided change. Most frequently, however, it is attended by aggravation of the symptoms; the stools passing from a mucous to a serous, sero-puriform, or grumous state. At its commencement, especially in the less inflam- matory cases, little fixed or constant pain is felt; but as it advances through the coats, pain, in some form, Is experienced. At an advanced period, especially when sphacelating ulcers exist, the stools become dark brown, muddy, or watery, and smell like washings of meat. The blood discharged is often of a darker colour, and some- times mixed either with an ichorous sanies, or, in the more sub-acute or chronic cases, with puru- lent streaks. When the blood is in large quan- tity, and unmixed with the rest of the dejection, ulceration low in the canal may be inferred. 55. p. Extension of inflammatory action to the peritoneum, or the omentum, or to the mesentery, is generally owing to ulceration, and may occur either previously, or subsequently, to perforation of the intestinal parietes. If great increase of pain, with heat, fulness, and tension of the abdomen, distressing anxiety, restlessness, inability to sleep, frequent retchings, and copious discharges, per anum, of morbid secretions and faecal matters which had been retained while the spasmodic action of the bowel was in full force, supervene at an advanced stage, extension of inflammation to the peritoneal coverings may be inferred; and, if these symptoms take place suddenly, and are quickly followed by very painful meteorismus, hiccup, cold sweats, sunk countenance, jactita- tion or delirium, rapid and laborious breathing, a very wiry or small, irregular, and weak pulse, cold extremities, &c, they may be imputed to per- foration of the bowel. Inflammation may also extend, generally with ulceration of the tunics, from the caecum to the appendix vermiformis, and thence to the peritoneum; or to the external con- necting cellular tissue, giving rise to abscesses in the right iliac fossa, that may open either into the caecum, or externally. (SeeCecum, § 19. 21.) A case of this description was treated by me in a warm climate, in 1817. It had been neglected in its early stages, and a very large abscess had formed and burst into the caecum ; extensive ulceration and sphacelation of this part being found on dis- section. 56. y. Gangrene seldom proceeds, even in the most severe cases, further than the mucous and submucous tissues ; excepting in warm climates, where sloughing ulcers, sometimes of large size, penetrate all or most of the coats. This change is commonly occasioned by the extension of the inflammatory action to the tissues underneath, and the consequent detachment and death of the portion of this coat covering the parts particularly affected; as the cuticle is detached by the effusion of fluid underneath it, when the vascular tissue of the skin is acutely inflamed. In such cases, portions of the partially sphacelated membrane hang loose in the canal, whilst the more external tunics are altered in colour, and softened. The symptoms indicating the commencement of spha- celation of portions of the mucous coat, are those detailed in the preceding paragraph, followed by leipothymia, or syncope when the patient is raised; a sudden remission of the tormina, abdominal pain or heat; singultus; cold, shrunk, and be- dewed countenance and extremities; sense of cold in the abdomen; involuntary motions; lividity of the lips and cheeks ; partial convulsive movements ; extreme prostration, and the supine posture ; glassy, inexpressive state of the eyes; cadaverous or very foetid smell from the evacu- ations, and the body; and, lastly, insensibility. 57. ii. The Chronic forms, besides terminating in ulceration and extension of inflammatory action to the serous surfaces, often superinduce thickening of the coats, and stricture, iii some part of the co- lon or rectum, or of both, frequently with dilatation of the portion above the contraction ; ultimately terminating, in some instances, in rupture of the more dilated and attenuated or ulcerated part, and effusion of the intestinal contents into the perito- neal cavity. In some cases, ascites comes on, or oedema ofthe lower extremities, or both, and the patient sinks in an exhausted and dropsical state. 58. VII. Appearances on Dissection vary with the form of the disease. In the inflammatory varieties, they are limited to the large bowels, and parts immediately connected with them; but in the asthenic and complicated states, especially in the scorbutic, the changes are much more extensive. — a. Upon opening the abdomen, the omentum is sometimes adherent to the superficial convolutions i of intestines, or to the brim of the pelvis, or to some part of the abdominal parietes ; but it is oftener drawn up to the arch of the colon, or to one side. The bowels, externally, present merely changes of capacity and colour, unless partial or general peritonitis have supervened. They are commonly distended by flatus, and variously coloured in different cases or parts, and frequently without the external colour having reference to the state of internal change. The large bowels feel in one place thick and doughy, in another thin and membranous. The colon is sometimes dis- placed or elongated, from relaxation of the lon- gitudinal bundles of fibres ; the transverse arch hanging down in a loop, or the sigmoid flexure passing over to the right side (Annesley, &c). Contractions of a considerable part of the colon are frequent, and sometimes the constrictions resemble those made by a ligature,— the parts above being distended and thinned ; they are firm and almost cartilaginous in some chronic cases, and seated chiefly about the sigmoid flexure and arch ofthe colon, and more rarely in the rectum. Adhesions of the peritoneal surface of the colon to the adjoining parts, and effusions of lymph, or of serum, into the peritoneal cavity, also, are often seen. 59. 6. Internally, the bowels present extensive and numerous changes. The villous coat is dif- ferently shaded in different parts ; and varies DYSENTERY —Diagnosis. 711 from a pale grey or sea green to a bottle green I or violet colour; or from a pale pink to a bright i red, or reddish brown, shaded with black. In some, the most opposite colours pass abruptly into, one another. Large portions of coagulable lymph are sometimes found partially adherent on this surface. Excoriations of the mucous epi- thelium, the excoriated parts presenting a choco- late tint; detachment of portions of the villous coat, sinuosities existing underneath the parts in- tervening; softening oi the internal tunics; ulcer- ations, in all the forms described in the article Digestive Canal (§36—40.); and sphacela- tion of portions of the mucous and submucous tis- sues; are the most frequent appearances, and are met with, in various grades, in all the forms of the disease. The ulcers are either small, nume- rous, and clustered, or large, distinct, and few. They are often dark, extensive, and sloughy; the parts in which they are seated, as well as those surrounding them, being softened, or very easily torn, particularly in the asthenic varieties, and in I the scorbutic complication. They are frequently elevated on a thickened or hardened base, in the more chronic cases, as described in § 36. c. of the article now referred to; or they present exuberant fungous or fleshy granulations on their surfaces. In some instances, their centres are very dark or blackish (Pringle, Monro, &c). Deficient vital cohesion of the coats of the bowels, they being occasionally torn as easily as wetted paper, is very common in the more asthenic varieties. In prolonged inflammatory cases, thickening and almost cartilaginous induration of a considerable part of the colon are not infrequent, the thickened or indurated portion being also contracted in cali- bre. In such cases, the parts above the con- tractions are greatly distended, the coats being thinned, ulcerated, and even lacerated; the con- tents ofthe bowel having passed into the peritoneal cavity, and occasioned rapidly fatal peritonitis. The cacum is extensively disorganised; and the parts surrounding it are, in some cases, inflamed, or in a state of suppuration, or sphacelation (An- ne s l e y and myself). The appendix vermiformis is also occasionally inflamed and ulcerated. The small intestines are very often inflamed, especially in the internal surface; and ulcerated in their low- est third, particularly in the asthenic varieties, and in the hepatic and scorbutic complications. In some instances, the ileo-caecal valve having been ulcerated, extensive intus-susception of the ilium takes place into the caecum and colon. Invagina- tions occur also in other portions of the intestinal tube, especially the ilium. (See Digestive Canal, § 18—48.) 60. c. The collatitious viscera are generally dis- eased in the asthenic and complicated states. The mesentery and mesocolon are more vascular than usual; and the glands of the former are inflamed or enlarged, more rarely suppurated, especially in situations corresponding to large ulcers. A dirty- coloured fluid is occasionally affused in the peri- toneal cavity in malignant or typhoid cases; and sometimes, also, in the thoracic cavities. The spleen is either enlarged or softened in the asthenic varieties, or when the disease is consequent upon periodic fever; and the liver is congested, in- flamed, suppurated, or otherwise disorganized, in the hepatic and scorbutic complications. Con- gestion of the portal vessels is very common in both the asthenic and sthenic forms. Injection and changes of colour of the internal surface of the stomach and duodenum, and accumulations of viscid thick bile in the gall-bladder, are frequent- ly observed. The pancreas is sometimes enlarged, and presses upon the common duct. The urinary bladder is occasionally inflamed about its neck, or in its external tunics; and the prostate somewhat enlarged. In the dysentery recently epidemic in Ireland, Dr. O'Brien found the liver diseased in one half the dissections; the spleen in one fourth; the small intestines in two thirds; and the colon and rectum in all. In chronic cases, in the Bri- tish army in the Peninsula, the spleen, liver, pan- creas, mesenteric glands, &c, or any two or all of these, were more or less diseased (Sir J. M'Gri- GOR,Dr. Ferguson, Dr. Somers, Dr. Forbes, &c). 61. d. In the most malignant varieties, and in the scorbutic complication, the internal surface of the whole digestive tube is of a livid, purple, or dark colour; with patches of ecchymoses, exco- riation, ulceration, and sphacelation. The villous coat, particularly in the seat of ecchymoses, may readily be rubbed off; and the ulcers have a foul and dark appearance. The liver is sometimes large, soft, and spongy; at others, pale and soft, especially in cases where the loss of blood has been very large. The spleen is sometimes so softened as to appear semifluid or sphacelated. The heart is often partially softened or flaccid; the pericar- dium and pleural cavities containing a bloody, dark, and dirty serum. The lungs are often con- gested; the bronchial lining dark, or ecchymosed; and the blood in all the large vessels is semifluid, black, and of a very loose texture. Indeed, the vital cohesion of all the tissues is, in these forms of the disease especially, more or less lost. In the dark races, the digestive mucous surface is usually paler and softer than natural, or discolour- ed or sphacelated; the follicles enlarged or ulce- rated; the coats of the caecum and colon very easily torn; the liver pale, soft, and small; the spleen enlarged and softened; the pancreas occa- sionally enlarged, and the mesenteric glands always enlarged, or otherwise diseased. 62. VIII. Diagnosis.—Dysentery often very nearly approaches either fever, diarrhaa, cholera, or colic; and it frequently supervenes upon one or other of these diseases; fever, diarrhcea, &c. almost insensibly passing into it.—(a) Fever, es- pecially some of its endemic and epidemic forms, sometimes assumes an enteric character, closely resembling the asthenic states of dysentery, partic- ularly as respects both the frequency and charac- ter of the evacuations; a circumstance which led Sydenham, Blane, Jackson, and others, to consider the latter as fever turned in upon the bowels. Although, in some cases, the one may insensibly pass into the other, yet idiopathic fever, with predominant enteric affection, will be dis- tinguished from dysentery by the more marked constitutional affection before the bowels become disordered, by the much less pain and difficulty in the excretion of urine, by the absence of severe tormina and straining, and by a more feculent state of the evacuations, than in any of the forms of the latter disease. It has been sup- posed by many writers, that the more asthenic oi malignant states are mere associations of dysentery with adynamic or typhoid fever: but, instead of 712 DYSENTERY—Diagnosis. viewing these states as complications of two diseases distinct from each other in their nature and seat, it would be more philosophic to consid- er them as coexistent results of the operation of certain concurring causes upon the economy ; which causes, according to their natures, and the predisposition and habits of the affected, induce effects partaking more or less of the characters of either fever or dysentery. Iu most instances, where the disease seems to have been thus mix- ed, animal emanations, a close and impure air, or other depressing and contaminating agents, acting either internally or externally, and aided by epidemic influence, have manifestly existed. But it is rather to the presence of those agents, in such a form as to act upon the excreting viscera and prima via, or in such combinations as to deter- mine their effects to this quarter, assisted by ante- cedent disorder or predisposition of the digestive and excreting viscera, that the adynamic states of dysentery are to be imputed. Thus an impure or infected air — either short of inducing, or even sufficient to induce, the worst forms of fever— may produce a malignant or typhoid state of dys- entery, when aided by unwholesome water or diet; and this latter cause, unassisted by the for- mer, may also occasion the same disease, in a similar or a less severe form, in those greatly predisposed. Hence, according to the nature and .concurrence of causes, will effects upon the frame be induced; which will insensibly approach fever on the one hand, and the most simple and perfect dysentery on the other. 63. This modification of the disease, with the nature of the disposing and exciting causes, is fur- ther illustrated by the intermitting and rheumatic characters occasionally assumed by it, in both its endemic and its epidemic states of prevalence. In localities where marsh miasmata abound, and where the water or the food are unwholesome, or other causes of dysentery prevail, this disease often either assumes, in both its acute and chronic forms, in warm climates especially, an intermit- tent or remittent type—most frequently the latter —or supervenes upon or passes into these, or into continued fever. Of this I have seen nume- rous instances; and similar facts have been re- corded by nearly all the writers on the diseases prevalent in the armies engaged in the last wars. In certain of its epidemics, especially those which prevail in cold and moist seasons, dysentery some- times follows, or is otherwise connected with, ca- tarrhal affections, as observed in those recorded by Strom, G.Baker, and Neumann; and it occasionally is complicated with rheumatism, particularly in one or more of the joints or extremities, the amelioration of the one affection being often followed by aggravation of the other. The association of dysentery and rheumatism, and their conversion one into the other, are stated by Dr. Sims to have been remarkable, in the epi- demic in London, during 1769 and 1770. A somewhat earlier and a more distinguished writer, —Dr. Akenside,—likewise alludes to this sub- ject, in a manner worthy of the most philosophic of our poets, and observes:—"Novimus praeterea, eadem tempestate et ob easdem causas rheuma- tismum quoque frequentissimum fieri;" whilst he states, in another place, that, although these dis- eases prevailed separately, they were, owing to the similarity of their causes, often coexistent, or consequent the one on the other: a circum- stance not confined to this climate, and occa- sionally observed in certain seasons, but also remarked amongst the natives of intertropical regions. 64. (6) Diarrluea is so very closely allied to dysentery, that they may be viewed as varieties or grades of the same morbid actions. Nosologists, iu their rage for drawing distinctions, which exist only in extreme cases, have wittingly overlooked the fact, that, between both diseases, there often scarcely exists a shade of difference; whilst, be- tween the extremes, the distinction is sufficiently wide, and easily made. Dysentery frequently follows simple diarrhcea, or diarrhoea attended by fever; and is itself also followed by diarrhoea, in some one or other of the forms in which it is described; and both diseases may be merely the sensible phenomena either of the irruption and excretion of morbid secretions, or of inflammatory irritation, affecting somewhat different portions of the alimentary canal. Yet, although thus very closely allied in nature and form, they are very often distinct, as respects—1st, the seat of disease; 2d, the affection ofthe system generally; and, 3d, the symptoms resulting from each.—a. Diarrhaa is generally sporadic, and never infectious;—p. It occurs at any season, and is more commonly a chronic disease than dysentery;—y. It is usually neither preceded nor attended by fever;—S. It is unaccompanied by severe tormina and straining; —t. In it, the evacuations are more or less abun- dant, and not bloody;—t. It is seldom attended by vomiting or heat of skin, or by early depres- sion of the powers of life, as observed in dysen- tery;—»,. The history ofthe disorder, particularly in relation to its causes and' constitutional disturb- ance, will point out many points of dissimilarity between it and dysentery. 65. (c) Cholera differs from dysentery,—a. In appearing only during the latter part of summer, and in autumn;—p. It is a most acute disease, running its course in from one to two or three days;—y. It is unattended by straining, or blood in the stools;— patient has once had the disease, are very com- mon, especially if he remain exposed to the en- demic or other exciting causes, as in hot climates and during campaigns or sieges; or if he be ad- dicted to intoxicating liquors. They are also fre- quent when the complaint has been associated with affections of the liver, or spleen, or conse- quent upon obstinate intermittents, and when recovery had not taken place until after it had assumed a chronic state. In such circumstances, slight errors of diet, or exposure to cold, and nox- ious emanations, will often speedily reproduce it. The numerous relapses observed in unhealthy lo- calities, and amongst soldiers and sailors, are chiefly attributable to a too early discharge from medical care, and return to irregular habits and injurious exposures; and to the abrupt resumption of a stimulating diet. 80. X. Treatment.—Towards the close of the last century, and at the commencement of this, the treatment of dysentery, as set forth in various papers and works, by authorities confided in at the time, was absolutely below the standard fur- nished by the ancients, and by writers in the six- teenth and seventeenth centuries, not merely in respect of the knowledge and appropriation of therapeutical means, but even as regards the just- ness of pathological views; without which, in- deed, no medicinal agent can be even safely pre- scribed. If any one think this assertion para- doxical, let him refer to the sources pointed out to him in the sequel; and. with a slight allowance for phraseology, he will perceive that, as to this disease, as well as to many others, knowledge has not been always progressive; and that the unsound and narrow doctrines in medicine, that sprang up soon after the middle of the last century, have contributed not merely to its retardation, but to its retrogression. The cant about experience, so recently raised, and kept up by those the least en- titled to the distinction it should rationally confer, threatens an equal, although very different, obstacle to the progress of medical knowledge, by being made without reference to the fact, that experience in medicine consists not in opportunities, or the number of objects seen, or even in the repetition of the same experiments or observations; but in the qualities of the mind of the observer; in due pre- paration for the task by literature,philosophy, and science; and in the application of them to the ob- ject successively investigated. Thus qualified, op- portunities will seldom be wanting, and the results will soon accumulate so as to enrich the mind of the inquirer to an extent to which the empirically — the ignorantly experienced, will ever remain a stranger; and will be of such a description, as can be attained only by a mind so constituted and so instructed. 81. i. Of Acute Dysentery.— The general indications of cure, are — 1st. To remove the causes, predisposing, exciting,and concurring; and, when it is requisite, or circumstances will permit, to place the patient in a pure and open air.— 2d. To subdue inflammatory ^action by antiphlogistic measures, when its presence is rationally inferred, or when the state of the attendant constitutional affection will admit of them, or to the extent to which it may be benefited by them.— 3d. To pro- mote the excretions of the skin and kidneys, and to determine the circulation to the cutaneous sur- face.— 4th. To remove, by gentle and appropriate means, the morbid matters that may remain or collect in the prima via, and to dilute and correct them.— 5th. To protect the mucous surface of the bowels from their irritating and excoriating action. — 6th. To correct the morbid condition ofthe cir- culating and secreted fluids, in the asthenic and ma- lignant varieties, or whenever this condition may be inferred, conformably with the views explained in the articles Blood, Debility, Disease, and Symptomatology.—7th. To support vital pow- er, if it fail in the progress of the sthenic forms,and early in the asthenic varieties, as being indispen- sably requisite to the correction of a morbid state of the fluids.— And, Sth. • To palliate urgent symptoms, or to arrest such as are attended by immediate danger, as soon as they appear. An appropriate use of energetic means will generally accomplish, simultaneously, two or more of these intentions. 82.A. Treatmentof the Sthenic Forms. -•—(a) Bleeding, general or local, or both, accor- ding to the severity of the disease and constitution ofthe patient, and repeated accordingly, is gener- ally requisite. The application of a number of leeches to the abdomen, in the slighter cases, or after venaesection in the more severe attacks, and of fomentations, or warm poultices, frequently re- newed, after the leeches have fallen off, will give much relief. If tenesmus or dysuria be urgent, and pain be felt along the sacrum, the leeches may be placed there or on the perineum, or cupping on these parts may be directed. Although vascular depletion is most serviceable early in the disease, yet it should not, in these forms, be 67 718 DYSENTERY — Treatment of its Acute States. neglected in the advanced stages, when it has been either omitted, or directed in too small a quantity, unless the symptoms are such as contra- indicate it. When fixed pain is felt in the region of the caecum, or in the course of the colon, leeches should be repeatedly applied until it is removed. 83._(6) Purgatives and laxatives have been long recommended, and employed with a most injurious want of discrimination, on the supposi- tion that the disease is caused, and kept up, by the lodgment of faecal matters in the colon; and yet, notwithstanding the general fallacy of the views which led to their employment, when ju- diciously selected and combined, they are often of much service. It must be obvious that such purg- atives as act principally on the colon and rectum are not suited to aninflammatory disease of these parts; and that, when there can be no collection of faecal or morbid matters to remove, the exhibition of them will merely aggravate the symptoms. It is, therefore, most important to ascertain, upon en- tering on the treatment of a case ofthe disease, as far as may be done, whether or no such matters may exist to the extent of requiring these remedies. If the patient has been seized after a constipated or even natural state of the bowels, if hardness and fulness can be felt in any part ofthe colon or caecum upon careful examination of the naked abdomen by the hand; if, together with these, the tongue be much loaded, and the matters evacuated offensive from the commencement; if the patient complain of a sense of stuffing or ful- ness in the course of the large bowels, and if pellets of fasces be evacuated; suitable evacuants are indicated. But, if the disease has been pre- ceded by diarrhoea, or by free faecal discharges, as it frequently is, they should either be withheld for a time, or very cautiously employed; the se- lection, also, being made with much care. When the patient is well informed, his sensations and account of the early symptoms should be duly weighed and attended to. Much mischief may arise, and discredit be reflected on the prac- titioner, by neglecting this very obvious indi- cation — by following blindly the dictates of either unsound theory or worthless authority, instead of being guided by common sense. I have repeatedly known persons who have been accounted igno- rant, but who were not necessarily without sound sense, complain bitterly, and lose all confidence in their medical attendant, and hopes of recovery, when directed to take cathartics, after, as they have expressed it, their insides had. been nearly purged out of them. — When, however, the patient has not had any feculent discharges for a considerable time, during the progress of the disease, although they may have been copious and frequent before the accession of the dysen- teric symptoms, a mild purgative should be pre- scribed, as being much less irritating than the retention, even for a short time, of morbid excre- tions; and its operation should be promoted by an emollient enema. Cooling or oleaginous purg- atives are preferable to others: and perfectly sweet castor or olive oil; or the following preparation, recommended by Vo g f.l ,and praised bySc h m i dt- mann; or Formula? 144. aud 790. ; or either of the subjoined electuaries; may be tried:— . No. 199. K Extr. Jalap Resin, gr. xij.; San. Venet. er. vj.; tere probe cum Olei Olivte (vel 01. Lini. vel 01. Amv- gdal. Dulc.) 5 ij. Capiat 5 ss. omni node. No. 200. R Pulv. Jalap. 3«.; Potass* Supertart. Jiij.j Pulv. Ipecacuanha; gr. j. ; tere bene simul, et adde Pulv. Rad. Glycyrrh. 3jss.; Syrup. Zingiberu (vel Theriac. Com- mun.) ^ss. M. Fiat Elect., cujus sumatur dimidium. No. 201. R Potassae Supertart. in Pulv. trit. 5j«-> Po- tassae Nitratis 3j.; Confect. Sennae Jij. ; Syrup. Aurantii q. s. ut fiat Electuarium, cujus capiat coch. j. vel ij. minima; super bibendo dose mist. seq. No. 202. R Magnet Ustae ^j.; Camphorae eubactae gr. ij.; tere et adde Vini Ipecacuanha: 5 J9S- i Aqua Mentb. Virid. ^vijss.; Syrup. Aurantii 5 U- F'at .Mist., cujus cupiat coch. iij. larga, cum dose Elect, supra praescripti. If castor oil be employed, it will be advisable to exhibit it on the surface of some mucilaginous or emollient vehicle, and to add to it a few drops of laudanum. Whatever may be the purgative pre- scribed, it should be assisted by emollient and laxative injections, such as F. 144.; or of tepid water ; or fat mutton broth, well strained ; or linseed, or sweet, or almond oil. Tenesmus is sometimes aggravated by large enemata. They should, therefore, be of small bulk; or the irrita- tion should be first allayed by an opiate, or an opiated and litharge (see F. 682, 683.), or a bel- ladonna, suppository. 84. (c) Refrigerants may be exhibited, either alone, or with diaphoretics and diuretics, and in emollient and mucilaginous vehicles (F. 866.); especially after the above means have been em- ployed, and when there are much fever and sense of internal heat. The nitrate of potash may be given with ipecacuanha and opium (F. 642.), or with small doses of camphor (F. 36. 460.), and of ipecacuanha (F. 39.); or, in solution with spirit, aether, nit. (F. 436.), liquor ammoniae acet., and opiates. The muriate of ammonia may like- wise be exhibited, as in F. 352. and 431. 85. (d) Opiates, fyc. are productive of the greatest benefit, after depletion; and should be prescribed in large doses. If faecal matters have been carried off, during the diarrhcea often usher- ing in the disease, they ought to be exhibited directly after depletion; and, in all cases, after the operation of a purgative. But much will depend upon the medicines that may be given with them. Of these, ipecacuanha is the most important. From two to four grains of opium witri as much ipecacuanha should be prescribed for a dose ; and, if not retained, repeated in a short time. These should be taken in the form of pill, which may be washed down by a refrigerant and emollient draught; or the ipecacuanha may be given in a similar vehicle, with from thirty to forty drops ofthe tinct. opii comp. (F. 729.), and repeated according to circumstances. This medi- cine will ameliorate the symptoms and determine to the cutaneous surface, especially if its action be promoted by the slightly warm bath, or semi- cupium or hip-bath; and by frictions of the sur- face subsequently. After a decided effect has been produced by these, Dover's powder maybe prescribed at short intervals, so as to keep up the action on the skin; and the abdomen should be swathed in flannel. Opiates may be employed also in the mucilaginous enemata already recom- mended (F. 143. 147. 152.), and in the form of suppository. 86. (e) External derivatives and rubefacients are sometimes of service after depletion and the above means have been duly employed. A large blister may be placed upon the abdomen; but it should be removed as soon as it has produced redness, and be followed by warm bread and DYSENTERY.—Treatment of its Acute States. 719 water poultices. The turpentine epithem will be ' found still more generally of use, and will not so much increase the irritation experienced in the urinary passages as the blister frequently does. In cases where this symptom is severe, mucilages with soda, nitre, small doses of camphor, and opium, will give relief. When it is urgent, tenes- mus is also a prominent feature; the means already advised, especially local depletions, either from the sacrum, or from the perineum, small emol- lient and cooling injections, and opiate supposito- ries, being the principal remedies. If the sthenic forms of the disease yield not to the treatment now advised, or if it pass into the chronic state, recourse must be had to such of the methods of cure, and medicines, hereafter to be noticed, as may seem most appropriate to the circumstances of the case. When much debility is complained of, after tormina and tenesmus have been removed by an antiphlogistic treatment, mild bitters, as the infusion of calumba, or infusion of cinchona, with liquor ammonias acetatis, tinctura camphorae com- pos., and small doses of the vinum ipecacuanhas, will be productive of much benefit. Costiveness should be carefully guarded against, by the occa- sional exhibition of a gentle purgative, as directed above (§ S3.), and of aperient and emollient enemata. 87. Among Europeans in hot climates, the disease requires a prompt and decided use of anti- phlogistic remedies, inasmuch as the inflammatory action is, in these cases, more intense, and ar- rives more rapidly at an unfavourable termination. The treatment, however, in principle, is the same as that advised above. The good effects of large doses of ipecacuanha and laudanum — from half a drachm to a drachm of each — after bleeding, have been shown by Mr. Playfair; and of smaller doses — from three to seven or eight, with an equal quantity of some bitter extract — also after requisite depletions, have been found equally beneficial byBALMAiN and Twining; whilst the impropriety of an indiscriminate use of mercury, especially calomel, in this disease even as it occurs in India, has been acknowledged by these writers, Mr. An.nesley, and others. Although dysentery, in persons thus circumstanced, as- sumes the inflammatory form, or that ofcolonitis (as it has been improperly called by some writers, as the rectum, caecum, and often the small intesi tines, are also affected), especially soon after their migration to a hot climate; yet the attendant constitutional affection is not always of a sthenic kind, but frequently assumes either the simple asthenic (§ 25.), or the bilio-adynamic (§ 28.), or malignant forms ; especially in those who have resided long in the country, and where the endemic causes abound. In many cases, also, the symptoms are acutely inflammatory at the commencement, and rapidly pass into a very asthenic state, even before either of the unfa- vourable changes pointed out above have begun. In such, the antiphlogistic treatment should be early employed, and exhaustion met, as soon as its signs appear, by the remedies about to be recommended for the asthenic varieties. In some instances, also, particularly in persons circum- stanced as now stated, the dysenteric affection is entirely symptomatic, either of abscess in the liver, or of interrupted circulation through the ramifications of the vena porta, — pathological conditions which should be carefully investiga- ted, as they require very different plans of cure. (See Liver — Chronic Inflammation and Sup- pur, of.) 88. B. Of the Asthenic Forms.—(a) In the simple asthenic form, ipecacuanha with opium, the warm bath, and gentle purgatives with ape- rient and emollient enemata, conformably with the views now stated (§ 83.), will frequently remove all disorder. In most instances it will be requi- site, and particularly if the biliary secretion be ob- structed or vitiated, to give a full dose of calomel (from ten to fifteen grains) with two or three grains of opium, and one of ipecacuanha, a few hours before the purgative is exhibited; and, when dull and constant pain is felt in any part of the abdomen, or tenderness on pressure, a number of leeches should be applied, and be followed by the warm turpentine epithem. Venassection has been found injurious in this form of dysentery, espe- cially when epidemic during very moist seasons. An ipecacuanha emetic will often be of service at the commencement; but if retching become ur- gent, opium in the form of pill, sinapisms on the epigastrium, croton oil rubbed on the abdomen; the warm bath, orhip bath, or semicupium; and nitre, with emollients ; will both relieve this symptom, and allay the tormina and tenesmus. Mucilaginous mixtures, with paregoric elixir and vinum ipecacuanhae, are generally serviceable. Emollient clysters and suppositories, with opium, are also requisite. I have seen the preparations of hop productive of great relief in this form. They may be prescribed with camphor mixture and liquor ammonias acetatis, or with emollients (F. 839, 840. 871.) and diuretics. In the more severe cases, or when the disease does not yield to the above remedies, full doses of camphor, with opium, or with Dover's powder, or with the addition of nitre (F. 36. 39.), may be given every five or six hours, and pieces of flannel made warm and moistened with either of the liniments, F. 297. 307. 311., be kept upon the abdomen until relief is obtained. Although faecal matters and disordered secretions may have been evacuated before the dysenteric symptoms had appeared, yet it will be necessary to have recourse to mild pur- gatives, from time to time during the progress of the disease, in order to excite the functions ofthe excreting organs, and to evacuate such morbid secretions as may have collected. The purga tives and aperient enemata recommended above (§ 83.) may be exhibited, or the compound infu- sion of senna with an equal quantity of infusion of calumba or gentian, and a little soluble tartar and compound tincture of cardamoms. If the disease be likely to become obstinate, equal quantities of turpentine and castor oil, taken on the surface of milk, or of an aromatic water, and repeated every second or third day, will be most efficacious. After the tormina and tenesmus are removed, mild bitters and tonics; and, in some cases, as- tringent tonics and absorbents, with the treatment advised in the article Diarrhcea (§ 29—33.), will generally remove all remaining disorder, if the state of the secretions and of the bowels be duly attended to. If the complaint degenerate into a chronic form; or debility become a pro- minent feature; and if the excretions indicate, with the state of the surface and tongue, a pro- gressive deterioration ofthe fluids and soft solids; 720 DYSENTERY — Treatment of its Acute States. the means about to be directed for these conditions must be employed. 89. (b) In the nervous or typhoid, and malig- nant forms (§ 26.), the sixth and seventh indica- tions of cure should be particularly entertained, and with due reference to the third, fourth, and fifth. From one, io three, four, or even more grains of camphor may be given every three or four hours, with three of hydrargyrum cum creta, two of ipecacuanha, and one of opium, in the form of pill; and if it be thrown off the stomach, it should be persisted in nevertheless. The patient should also be put into a warm bath; the tem- perature of which ought to be gradually raised while he is immersed in it; and, having been well rubbed upon coming out of it, be placed between warm blankets, in order to promote the action of this medicine on the skin. This inten- tion will be furthered, if the stomach be not very irritable, by draughts containing liquor ammonias acetatis, potassas nitras, or any other appropriate neutral salt — The action on the skin should be kept up for a considerable time by the medicine, and promoted by emollient diluents, such as the decoction of liquorice or of linseed, &c. If these means fail of giving relief, flannel wrung out of hot water, and moistened with spirits of turpentine, should be applied to the whole abdo- men, and allowed to remain as long as the patient will endure it. The usual effects of this epithem are, a most copious perspiration, with burning heat ofthe skin where it is applied; and, conse- quently on these, a total remission of the tormina and tenesmus, followed by sound repose procured by the pills which have been taken. In advanced stages of the complaint, when the internal con- gestion or determination is very great, and the skin is harsh, dry, and livid, repeated applica- tions of this epithem, as warm as the patient can endure it, are sometimes requisite to its full effect. In a case which I lately treated under very un- favourable circumstances, it having been con- sequent upon continued fever, in a lady long subject to disorders of the colon and rectum, a quart of the spirit was thus employed before redness of skin was produced; although it was warmed by immersion in warm water before the flannel was moistened with it This pa- tient ultimately recovered. To these means may be added, the emollient and anodyne enemata already recommended; and suppositories of opi- um, if tenesmus and dysuria be urgent, and the rectum very irritable. 90. In these dangerous forms, notwithstanding full evacuations of foscal matters may have ush- ered in the disease, it will be requisite to carry off, from time to time, by suitable purgatives, such morbid matters as may have accumulated. To many cases, the purgatives and enemata pre- scribed above will be appropriate; but where the stools are very offensive, or contain much dark blood; when the powers of life are depressed; or when stupor is present; and more especially if petechias or discolouration of the skin be observ- ed ; the draught with castor oil and turpentine directed above (§ 88.), or F. 216., should be ex- hibited, and its effect promoted by either ofthe enemata, F. 135. 150. and 151. In this state of disease, it is important to evacuate morbid mat- ters by such means as will at the same time restore the tone of the digestive mucous surface, and of the vessels opening on it; and I believe that there is none that exerts this influence more efficaciously than those now named. Next to these, rhubarb in powder, with camphor, and cal- omel, or hydrarg. cum creta; or cinchona, with senna (F. 86.); or the infusion of gentian and senna (F. 266.); or infusions of cinchona and rhubarb; or the preparations of cusparia and rhu- barb; will be found the most efficacious. 91. If the powers of life be much depressed, the circulating and secreted fluids will generally become more and more vitiated. Our chief ef- forts should then be directed to counteract this tendency. With this view, the decoction or in- fusion of dnchona and serpentaria, with camphor, and small doses oi nitrate of potash, or oi muriate of ammonia, or with the chlorate of potassa, or of soda, may be prescribed; and either of these, or the chlorate of lime, may likewise be administer- ed with camphor in mucilaginous enemata, espe- cially when the stools are very offensive; taking care to prevent the accumulation of morbid se- cretions by occasionally resorting to the aperient draught and enema directed above (§ 90.). The infusions of cascarilla, of calumba, or cusparia (F. 201.), or the decoction of tormentilla (F. 78.), may likewise be taken, with these or simi- lar additions. When the evacuations are copi- ous, as well as morbid, their excess occasioning vital depression, it will be necessary to control them by adding opium, and the usual astringents, to the tonics now mentioned; and to excite the functions of the skin by the warm bath, frictions of the surface, and the application of the turpen- tine epithem to the abdomen. The terebinthina- ted medicines, also, already mentioned, are the most active aperients, and astringents at the same time, in this complaint, as well as the most certain and beneficial in their effects. Upon the whole, these severe states of the disease re- quire similar remedies to those enumerated iu the articles Blood (§ 157. et. seq.), and Debil- ity (§ 38)., and in the sections on the treat- ment of the adynamic and malignant forms of Fever. 92. (c) The bilio-adynamic form presents con- siderable diversity of character in different seasons and epidemics, and requires a modified treatment accordingly. When there is no tenderness or fulness at the epigastrium, an ipecacuanha emetic will generally be serviceable; but its operation should be followed by a full dose of calomel; and that, in a few hours, if faecal matters have not been already evacuated, by either of the mild purgatives prescribed above (§ 83.), and by emollient injections. When the patient complains of a burning sensation in the colon, or of scald- ing in the rectum, with great irritability, nitrate of potash, or muriate of ammonia, should be given in emollient or mucilaginous vehicles; and an opium and litharge suppository (V. 683.) administered; a similar combination of refrigerant and muci- laginous medicines being afterwards exhibited in enemata. In some cases, this form approaches nearly to that of sthenic vascular action, and then leeches are required to the abdomen; and will be most advantageously followed by the turpentine epithem. After these remedies, small doses of camphor, hydrargyrum cum creta, and Dover's powder, or simple ipecacuanha, may be taken j every two or three hours, and the warm bath, in DYSENTERY — Treatment of its Complicated States. 721 the manner above directed (§89.), occasionally resorted to. If this variety be characterised by great vital depression, the treatment already directed (§ 91.) must be employed. In all its states, and stages, it will be requisite to evacuate the morbid bile that is secreted, and to correct the diseased action in the liver; but beyond one or two full doses of calomel, either with or without opium, this medicine should not be persisted in; as it increases the irritation of the colon and rectum, and depresses vital energy. The hydrargyrum cum creta, as now directed, will be more efficacious; especially when assisted by the above means, and by emollient and muci- laginous diluents. 93. In the Dark Races, dysentery assumes the simply asthenic or malignant forms. In them, the treatment may safely be commenced by an ipecacuanha emetic^and followed by a purgative, the warm bath, and warm diaphoretics. Early in the disease, calomel with rhubarb and ginger; or powdered jalap with cream of tartar and some warm spice, will be appropriate; but enemata are also required. The habits and modes of living generally adopted by these races, independently of their more lax fibre, and much less tendency to inflammatory action, require an earlier and more active use of tonics, stimulants, astringents, and aromatic spices, with opium, than can often be safely attempted among Europeans. Purgatives, also, should be of a more stomachic and warm kind, and the functions of the skin especially pro- moted. The combination of ipecacuanha with tonics, astringents, opiates, and absorbents, according to the peculiarities of the case, is generally extremely efficacious after faecal matters have been evacuated. Camphor, catechu, the hot spices, and warm clothing, with the rest of the tonic and astringent treatment advised for the chronic state,and in Diarrhoea (§ 37.), should be resorted to, as soon as exhaustion supervenes, or when the disease becomes protracted. To Europeans long resident in hot climates, a nearly similar method to that now recommended is applicable, if the hepatic functions be regular; but, as in them the liver is very seldom unaffected, the means directed for the chronic form, which it usually assumes, is more generally appropriate; and the treatment should chiefly depend upon the nature of the primary or attendant hepatic disease. 94. C. Treatment of the Complicated State s. — (a) The association of acute dysentery with inflammation ofthe liver (§ 34.) requires de- cided and early general or local depletion, or both, followed by cooling purgatives, sufficient merely for the evacuation of morbid secretions. In this complication, the morbid state of the bile, and the rest of the hepatic symptoms, are the conse- quence of inflammation, and can be removed only by antiphlogistic treatment, and not by inordinate doses of mercury, which will merely over-excite an already excited organ, and accelerate sup- puration. Refrigerant, therefore, and cooling aperients, as the supertart. and tartrate of potash, tamarinds, manna, or the soda tartarizata; anti- monial or ipecacuanha diaphoretics; small doses of camphor, with nitre and opium; cooling and emollient enemata, and a very low diet; constitute the principal means of cure. When the patient complains much of burning heat or soreness in the abdomen, with scalding, &c. in the anus and urethra, the nitrate of potash, with sub-carbonate of soda, and spirit, aether, nit., in emollient ve- hicles; the muriate of ammonia in mucilaginous mixtures; suppositories of opium; and local de- pletions, followed by the warm terebinthinate epithem over the abdomen; are chiefly to be de- pended upon. If blisters be applied, they should be surrounded by a number of leeches, the former being removed as soon as they have produced red- ness, and succeeded by warm poultices. As the substance • of the liver is generally more or less acutely inflamed in this complication, and as mer- curials will not readily produce their specific effects, or act beneficially, whilst this state con- tinues, but will rather increase it, the exhibition of them with this intention can only occasion abscess, irritative fever, and exhaustion; and fur- nish one of the most injurious proofs of the " nimia diligentia," which is but too common in the treatment of this as well as of hepatic disease. Can any practice be more empirical, than to give the same substance to subdue over-excitement, which we find the most active in rousing torpid function, of an organ ? Having removed the acute symptoms by the above means, the insertion of one or two setons in either side, and keeping up a free discharge from them for a long time, with appropriate diet and regimen, and change to a healthy air, will generally complete the recovery. When the dysenteric affection is merely symptom- atic of abscess in the liver, the treatment advised for this condition (See Liver—suppuration of) should be employed. 95. (b) The complication with disease of the spleen is most common after intermittent and re- mittent fevers, and in unhealthy localities; and the symptoms are either but little inflammatory, or more or less asthenic. Local depletions even are seldom required in its treatment. Warm sto- machic aperients, as cinchona with rhubarb, ipecacuanha, and aromatics; emollient enemata with anodynes; the warm bath, followed by fric- tions of the abdomen with either of the liniments, F. 297. 311., upon coming out of it; ipecacuanha with strichnine, or sulphate of quinine, or sulphate of iron, or with tonic extracts; camphor with warm diaphoretics, and the medicines directed for the more chronic states, which it more frequently assumes, or passes into; are the most appropriate in this state of the complaint. When dysentery follows continued or periodic fever, disease of the liver or spleen, or of both, should be dreaded, as well as its rapid termination in ulceration; and means, conformably with what has now been ad- vanced, should accordingly be promptly put in practice. The most efficacious of these, are early local depletions — but only when the symptoms clearly indicate the propriety of resorting to them; the terebinthinate epithem applied to the abdomen, or large blisters, followed by poultices, and re- peated according to the urgency of the case; with the rest of the treatment directed for the asthenic states, according to the peculiarities of the case. 96. (c) The association of acute dysentery with scurvy, requires the removal of the exciting causes; a suitable diet, especially fresh meat and vegetables; the liberal use of lime juice, with sugar, mucilage, and opium; the carbonate of potash or soda in effervescence, with an excess of lime juice, particularly when the secretions re- 722 DYSENTERY — Treatment of its Complicated States. quire evacuation by gentle means; the decoction of cinchona with muriatic acid, or citric acid, or chloric aether; and the draught and enema con- sisting of turpentine and castor oil, when the haemorrhage is considerable, and the abdomen tumid or tympanitic, or when the state ofthe dis- charges indicate the propriety of exhibiting a purg- ative. If lime juice is not to be procured, lemon juice or citric acid should be substituted. When the debility and oozing of blood from the bowels are great, the tincture of the muriate of iron may be given in the infusion of quassia, or the infusion of catechu may be exhibited with other astrin- gents, and with aromatics, warm spices, and the tinctura opii comp. (F. 729.). Carbonate of ammonia may also be taken in effervescence with an excess of dtric acid, or lime juice; ipecacu- anha, aromatics, and the above preparation of opium, being added. In the more urgent or ob- stinate cases, the warm nitro-muriatic solution should be daily applied over the abdomen, or added to mucilaginous and emollient enemata. It may likewise be used as a gargle, wheii the state of the mouth requires such means. The nitro-muriatic acids may also be taken internally with small doses of the compound tincture of opium, when citric acid or lime juice cannot be obtained. The chlorates may be prescribed with camphor, and opium, in mucilaginous vehicles; and administered, in a similar form, as enemata. During treatment, the diet should be regulated, and the excretions carefully observed. When the bile is scanty, and the stools without fasces, a fewr grains of blue pill may be given at night, and a full dose of magnesia in aromatic water the next morning, followed immediately by a glass of lemonade, or a draught with lime juice or citric acid, — the combination thereby formed in the stomach proving an agreeable purgative; or the hydrargyrum cum creta, with rhubarb, may be taken at bedtime, and the oily draught and enema already mentioned the following day. Aromatic confection, with magnesia; or creta- ceous and other absorbents, with ipecacuanha or Dover's powder; are also serviceable, when the bowels are much relaxed and griped, and the stools become frothy and acid. Cretaceous me- dicines should not be given while the citric acid or lime juice is continued; but subsequently, in the form now directed, or with astringents, tonics, and warm spices,, when the disease seems dis- posed to assume a chronic form, they are often beneficial, assisted by warm clothing, suitable diet, and the occasional exhibition of mild pur- gatives, so as to prevent the injurious retention of morbid matters, and promote the digestive and secreting actions. In the early stage of con- valescence, a similar treatment, with vegetable tonics; and the exhibition of these with aperients, when the bowels become sluggish; should be per- sisted in. The daily use, for some time, of either of the balsams, according to the peculiarities of the case, combined with a suflicient quantity of magnesia to form a pilular mass, will more ef- fectually restore the tone of the digestive mucous surface, and keep the bowels open, than any other means. Removal to a dry, pure, and warm air will accelerate and establish recovery. 97. (d) Dysentery is less frequently compli- cated with worms, in this country, than, perhaps, in any other. Worms are either so extremely common in the inhabitants of low and moist localities, and still more so in the dark races, especially among those who have not a sufficient supply of salt as a condiment; or they predispose so remarkably to the disease — or rather, the state of the digestive organs that favours their gene- ration disposes to it; that a very large proportion of dysenteric cases in the former, and nearly all in the latter, are thus complicated. The judi- cious use of anthelmintics — the decoction of the bark of the pomegranate root; the male fern, &c, followed by castor oil; and especially the terebinthinated draught and enema already re- I commended (§ 90.), — will generally remove the disorder. When it has arisen from the want of ! salt, this substance in sufficient quantity, with warm spices, vegetable tonics, and subsequently chalybeate preparations, will soon have a decided effect; but, without salt, other means cannot be depended upon. This complication is not infre- quent in children; the above remedies, or such as are most appropriate of those mentioned in the article Worms, being also suitable to them; but when the disease is removed, a course of chaly- beates and change of air should be prescribed. 98. (e) The hamorrhoidal complication is most | speedily relieved by local bleeding from the sa- [ crum or perinasum, followed by fomentations; the hip-bath; full doses of Dover's powder, es- pecially at bedtime: opiated, or opium and litharge, suppositories; and by the supertartrate of potash, with nitre and confection of senna, when an aperient is required. Cooling diapho- retics, and various refrigerants in mucilaginous or emollient vehicles, taken by the mouth, and in- jected per anum, in small quantity, are often use- ful adjuvants. When the disorder is attended by much pain about the anus, a cooling and anodyne ointment, after having recourse to warm fomen- tations, will often give relief. The extract of bel- ladonna, in an ointment of this description, will be most effective, as it subdues the morbid sensibility, and removes the spasm of the sphincter, which aggravates the pain in these cases. 99. (/) The complication with rheumatism (§44.), or catarrh, requires the frequent use of the warm bath or semicupium; and full doses of camphor, and ipecacuanha, or Dover's powders, in oleaginous or mucilaginous vehicles; or anti- monial diaphoretics with opium, if there be much febrile excitement and heat of skin. If the symp- toms are inflammatory, general or local deple- tions, or both, should precede the exhibition of these; and, if the biliary secretion be either ob- structed or vitiated, a full dose of calomel, or of the milder mercurials, should be given, and be followed by a gentle purgative, and that by an aperient and emollient enema. When the disor- dered secretions are evacuated, warm diaphoretics, especially camphor with opium; small anodyne injections; opium suppositories, and the constant use of flannel next the skin; will remove the dis- order. When severe rheumatic pains are felt in the lower extremities, opiate suppositories, after morbid matters are evacuated, will give great re- lief. In some instances, the pains in this situ- ation depend upon the retention of faecal or hard- ened substances in the caecum, or about the sig- moid flexure of the colon. In this case, fulness or hardness will be felt in these regions, on a care- ful examination of the abdomen; and appropriate DYSENTERY — Treatmei purgatives, aided by laxative clysters, will be re- quired, and should be repeated until the collection is evacuated. 100. ii. Treatment of the Sub-acute and Chronic Forms.—A. Of the more simple states. — The intentions of cure by which we are guided in the acute, should, with little modification, be entertained in the chronic, forms. When the symp- toms continuing after an acute attack consist chiefly of either frequent or copious evacuations, without tormina or straining, the appetite, pulse, and strength improving, or remaining unimpaired, astringents or opiates should not be prescribed ; for the discharges are the means of bringing about a resolution of the inflamed and tumefied viscera. In such cases, the stools are usually of a good colour, and are feculent and fluid. But, if the motions be attended by abdominal soreness, in- creased on pressure; or by a sense of heat; or by griping, tormina, or tenesmus; if they be slimy, or sanguineous; and if the patient complain of thirst, with fever and restlessness at night; nature requires the judicious assistance of art. Here vascular depletion, most frequently local, although it may have already been practised, and more espe- cially if it have not been resorted to, is required to an extent which the constitutional symptoms will indicate. If, however, the strength is too far sunk, or the asthenic characters are too pro- minent to admit of this measure, the warm epi- them already described (§ 89.), or blisters to the abdomen, followed by a succession of poul- tices, and these by the warm bath, a thick flannel bandage around the abdomen, and stimulating frictions of the surface, and of the lower limbs, will sometimes be serviceable. 101. In all cases, the state of the biliary secre- tion and of the liver should be carefully ex- amined. If the investigation furnish no proof of acute disease, or of abscess of this viscus, and if the bile be scanty or altogether obstructed, cam- phorated mercurial frictions on the hypochon- drium, blue pill or hydrargyrum cum creta, with ipecacuanha or Dover's powder at bedtime, and a mild purgative, such as cream of tartar, with confection of senna and extract of taraxacum in the form of electuary, in the morning, will often increase and improve the bile. If mercurials have not been previously used, and if no tender- ness or soreness be felt in the region of the liver, nor oppression of breathing, dry cough, nor recur- ring chills or horripilations alternating with hectic flushings,, &c, one or two full doses of calomel, with or without opium, may precede these medi- cines; the operation of which may be assisted, and the state ofthe large bowels improved, by emollient and oleaginous injections. After these means have been tried without benefit, the em- plastrum ammoniaci cum hydrargyro may be placed over the abdomen; and one or two grains of hydrarg. cum creta, or of blue pill, with one of ipecacuanha, and as much camphor, taken thrice daily, with a draught containing a drachm of the extract of taraxacum, or consisting of the decoc- tion of the recent root. As long as the stools are deficient in bile, astringent tonics will seldom prove permanently serviceable; but if the above medicines run off too rapidly in the stools, the com- pound tincture of opium should be added to them. 102. When the foregoing means have failed, nitric acid with opium or laudanum; and the ap- t of its Chronic States. 723 plication of the nitro-muriatic add lotion over the hypochondria and abdomen; may be tried; or, instead of the nitric, the nitro-muriatic acid may be taken internally, in a very weak state of solu- tion, or employed as an enema, with the laudanum, F. 729. Enemata consisting of a weak infusion of ipecacuanha, or of the decoctum lini, with muci- lage, or of both, may be administered once or twice a day, while the acids are taken. If these fail, and if the debility be great, the chlorates, espe- cially those of potassa or lime, may be given by the mouth, or in clysters. 103. In the advanced stages, the infusion of cin- chona.of cinchona and rhubarb, either withorwith- out laudanum, or of catechu with aromatics and warm spices, are generally requisite, more espe- cially in the dark races; the same preparations be- ing also advantageously administered as enemata, either with or without mucilaginous substances. When the disease, like a gleety discharge, proceeds from relaxation of the internal surface of the large bowels, and.a habit of increased secretion, these means will prove of essential service. In many cases, the disorder is kept up either by too great indulgence in food, or- by the use of stimulating liquors. The diet should, therefore, be restricted; and the digestion of what is taken promoted either by the above medicines, or by the sul- phate of quinine or the sulphate of zinc in the form of pill, with inspissated ox-gall, or other medicines suited to the case. If we succeed in controlling the increased action of the bowels, an opposite state should be carefully guarded against, by the occasional exhibition of the means direct- ed above (§ 83.); or ofthe draught and enema already mentioned (§ 90.). Inattention to this precaution, and errors in diet and regimen, are frequently productive of relapses. 104. If diarrhoea continue after the acute symptoms longer than seems sufficient for the resolution of inflammatory action in the large bowels, and of congestion ofthe portal vessels, we may suspect that the quantity or kind of aliment is such as the digestive organs, and the biliary and other secretions, are incapable of changing into healthy chyle,— a large proportion of it en- tering into such acid or acrid combinations as its constituents dispose it to form. In these cases, the stools are frothy, have a sour odour, or are lien- teric; and tonics, with mild mercurials and anta- cids; the sulphate of quinine, as above recom- mended; the balsams with magnesia, and the liquor potassae, or the sub-carbonate of ammonia, with tonic infusions, aromatics, and small doses of Sydenham's laudanum (F. 729.); are required; whilst the abdomen and hypochondria are sponged with the nitro-muriatic solution; and the large bowels fortified by the tonic and mucilaginous injections already mentioned. 105. In the cases denominated " White flux," from the muco-purulent and gleety appearance of the discharge from the muciparous glands, and the absence of bile, a similar treatment to the above is required; with an occasional dose of calomel, or frequent and small doses of the mildest mercurials, as above directed. (§ 101.) The infusion of either cusparia, catechu, sima- rouba, calumba, rhubarb, cinnamon, &c, with vinum ipecacuanhae, aromatics, absorbents, and astringents, according to circumstances; the chlo- rates, or nitre with soda and emollients, in aro- 724 DYSENTERY—Treatment of its Chronic States. matic vehicles, and in clysters; assafcetida, with camphor and mucilage, in enemata; and the daily use of the salt-water warm bath, followed by frictions of the surface with a rubefacient and deobstruent liniment (F. 311.), and a flannel roller around the abdomen; may also be resorted to. 106. If the evacuations indicate ulceration (§ 54.)—which, indeed, is seldom altogether wanting in protracted cases—the above treatment, or mucilaginous mixtures with either of the bal- sams; emollient clysters, and the repeated appli- cations of large blisters, or rubefacients, to the abdomen, or the insertion of setons, are chiefly to be relied on, with the other means advised in the treatment of Diarrhoea (§ 32.), arising from this pathological state. 107. A form of chronic dysentery depends upon, or is kept up by, ulceration, or even by a single large ulcer, in the rectum, with or without pro- lapsus ani (§ 47.), the abdominal symptoms being slight, but the tenesmus constant and painful. For it, small injections of a solution of the sulphate of zinc, or nitrate of silver, or dilute nitric acid with opium, or superacetate of lead, with pyrolig- neous acid and laudanum; or of paregoric elixir with mucilage; or of simple camphor mixture; the balsams, or sulphur with cream of tartar, and tonics with deobstruents, being taken inter- nally, and a gently open state of the bowels preserved; will remove the disorder. In nearly all the more simple states of chronic dysentery, also, the same treatment may be appropriately employed as is recommended in the chronic states of diarrhoea, lientery, &c. (See Diarrhoea, § 29 — 33. and § 41. et seq.) 108. B. The complications of chronic dysentery are much more common than the simple states; and the most frequent are those with chronic affections of the liver, with disease ofthe mesen- teric glands, and with enlargement ofthe pancreas and spleen.—(a) If the liver be free from acute disease of its substance, or from purulent form- ations (See Liver —Inflam. and Suppurat. of), mercurials are often essentially requisite. But, even in such cases, they have been much too liberally employed, on the supposition that sali- vation is indespensable to the cure of this com- plication. Where,however,theseforms of hepatic disease exist, they should almost altogether be proscribed; and also, where the powers of the system are much reduced, even in the simple states ofthe disease, the extension of inflammatory irritation to the mesenteric and portal veins, or the absorption of morbid matters from the bowels (§ 77.), and consequent disease — especially purulent collections — in the liver, may be fa- voured or induced by prescribing them so as to produce their specific effects'. 109. (a) We often have little or no proof of the presence of chronic change in the liver, beyond the torpid state of its functions already noticed (§ 48.), viewed in connection with the habits of the patient, and the history of his former com- plaints, and of his present attack; but, in these, mild mercurials, in frequent and small quantities, in conjunction with alteratives and deobstruents (§ 101.), especially minute quantities of antimony, with ammoniacum, soap, and opium; or these with taraxacum in full doses; or this latter with the infusion of calumba; will be found the safest as well as the most efficacious remedies, parti- cularly when assisted by a camphorated mercurial ointment or liuiment applied over the hypochon- dria; or by the nitro-muriatic acid solution, employed either as a wash, a lotion, or on the surface of warm poultices; or by repeated blis- ters; or by issues or setons, and the ammoniacal and mercurial plaster over the abdomen, or a combination of it with other deobstruent and warm plasters. In these cases, we must be guided by the evidence we may have of change of the liver, and direct our treatment to its removal, conform- ably with the views stated in the article on the diseases of that viscus. When the stools are frothy, and deficient in bile, the hydrargyrum cum creta, or the blue pill, will be advantageously combined with inspissated ox-gall, extract of ta- raxacum, and small doses of Dov e r's powder, or opium. The sub-carbonates of the alkalies, or borax, may also be given with vegetable tonics, ipecacuanha, and the preparations of hops; either ofthe liniments, (F. 296. 311.), alone, or with the mercurial liniment, being daily rubbed upon the abdomen, or applied by means of a piece of flan nel moistened with it and placed under wash- leather,— which will protect the clothes from it, and prevent its evaporation. In the foregoing states of hepatic complication, change of air, horse exercise, or travelling, and a regulated diet and regimen, will materially assist the treatment. 110. p. A sub-acute, slight, or chronic form of dysentery is sometimes merely symptomatic of the advanced states of hepatic abscess, and occurs more frequently than the very acute complication alluded to above (§ 94.). It requires either a similar treatment to that now stated, or simply support of the powers of life, in order to enable them to over- come the disease. The arrest ofthe discharges in this state of the complaint frequently increases the hepatic malady, or occasions severe constitutional disturbance. Gentle tonics and restoratives, light or farinaceous food, and such astringents, ano- dynes, aud emollients as will merely control and soothe the bowel affection, until the above treat- ment, or that recommended for suppuration of the Liver, shall remove the principal or primary disease, are the most deserving of confidence. 111. y. When purulent matter collects in the liver, in an advanced stage of dysentery, the oc- currence can be explained only as attempted above (§ 77.); and, during the life of the patient, the symptoms will seldom warrant more than a suppo- sition of its having taken place. The facts, that a bad habit of body, and an asthenic state of the powers of life, are the chief causes of thefabsorp- tion into the blood of morbid matters from the seat of disease, and of the extension of inflammation from an ulcerated part along the veins; and that these changes induce those observed in the liver in such cases, should be kept in view in the treatment of the advanced stagesof dysentery,— particularly as it has been satisfactorily shown that a large proportion of unfavourable cases terminates fatal- ly, owing to the contamination of the circulating fluid produced in this manner, either with or with- out the concomitant lesions ofthe liver, of which particular notice has been taken. Conformably, therefore, with these facts, the remedies I have shown, in the article Veins, to be most efficacious in arresting the extension of inflammation along them, in preventing or counteracting the conta- mination of the blood, and hi supporting the vital DYSENTERY —Treatment powers, will be most beneficial, not only where th:s complicated state is inferred, but also in an advanced stage of the malady, and especially in its asthenic forms, where it is most desirable to prevent or arrest these very dangerous occur- rences. When the disease is symptomatic of the absorption of morbid matter from carious bones, foul ulcers, &c. (72. c), the principles and treat- ment now stated should be adhered to, and the chlorurets applied to the ulcerated parts. 112. (b) The complication with disease of the mesenteric glands frequently cannot be distin- guished from that with chronic change in the liver; but, when the stools are lienteric, and the abdomen hard and tumid, the former association may be inferred, although the hepatic complica- cation may also be present; the means now re- commended being equally appropriate to both. I have seen benefit derived, in some cases of the mesenteric complication, occurring in children, from liquor potassa, or Brandish's alkaline solution, in tonic infusions, with syrupus papav- eris or tinctura opii; and from the chlorate of potassa with Dover's powder, a terebinthinate draught and enema being administered every third or fourth day. More recently, the ioduretted so- lution ofthe hydriodate of potash, with very small doses of laudanum, or the ioduret of mercury in minute quantities, has also been prescribed with advantage, especially when assisted by the warm bath, and some one of the liniments or other external applications enumerated above. If the patient, however, complain of tormina, or if the stools be bloody, the daily application to the abdomen of some one ofthe ointments containing the preparations oi iodine (F. 766. et seq.) will be preferable to the internal exhibition of this substance. In this class of subjects, change to a dry and pure air, and the prolonged use of these medicines in very small doses, are requisite to success. The same treatment may be also em- ployed in the hepatic complication. But in the acute maladies of the liver, the preparations of iodine are often injurious. 113. (c) The complication with disease of the pancreas is even more difficult to be ascertained than that with mesenteric enlargement; but, even when confidently inferred, it does not seem to require a different treatment from that now re- commended.—In the splenic association, nearly similar measures to those already stated are also applicable. The preparations of bark; the sul- phate of quinine, and of the metals; and stomachic purgatives ; are more especially indicated in it; particularly when aided by emollient clysters, and the external applications described above (§ 109.). 114. (d) Chronic dysentery in the dark races, being characterised by relaxation of the mucous surface of the large bowels, and an adynamic state of the system, and differing not materially from chronic diarrhoea, will be most successfully treated by tonics conjoined with astringents, ab- sorbents, aromatics, and hot spices; by the warm bath; by injections with lime water and other astringents; and occasional stomachic or warm purgatives, in order to prevent faecal matters from collecting. Its principal complications, in these races, are with enlargement of the spleen, with worms, and with mesenteric disease; the two lat- ter especially. In the association with enlargement ofthe spleen, the sulphate of iron or other chaly- 61* of contingent Changes in. 725 beates, with rhubarb, and occasionally stomachic purgatives, are the most efficacious medicines. To the other complications, the treatment already prescribed (§97. 112.) is also appropriate. (See also Diarrhcea — Treatment of, in the Dark Races, §37.) 115. iii. Treatment of certain States and contingent Changes.—A. When dys- entery is prevalent, a recognition of the early symptoms, particularly those premonitory of an attack, as sunk pale countenance, griping pains with borborygmi, and irregular chills or horripi- lations, with or without diarrhoea or tenesmus, should lead to the adoption of means which will often ward off the disease or cut it short. Of these, the most efficacious is an ipecacuanha emet- ic; which may even be repeated until its free operation is procured, followed by a single full dose of calomel; and that, in two or three hours, by a purging draught, and a laxative enema. Af- ter these, a warm bath, the patient being well rubbed upon coming out of it, and placed be- tween warm blankets; and pills with camphor, ipecacuanha, and three or four grains of opium, repeated subsequently in smaller doses; will fre- quently remove all disorder. This plan, if em- ployed sufficiently early, is equally applicable to all the varieties of the disease. 116. B. (a) Extreme irritability, want of sleep, and distress at night, during the most acute at- tacks, often exhaust the strength of the patient, and require either very large doses of opium, or opiate suppositories, or small opiate injections, es- pecially after coming out of a tepid or warm bath —a tepid bath if there be much heat of skin o* attendant sthenic diathesis, and a warm bath if the constitutional affection be of the asthenic kind.— (b) Excessive irritation in the rectum, and dysuria, may be alleviated by the treatment directed above (§84, 85.), and by small injections — from three to five ounces — containing either opium, or the extract of hyoscyamus, or the extract of bella- donna, or F. 137.; recollecting, however, that this latter will often produce much disorder, if too freely employed. In a case where I prescribed it, in 1826, with remarkable benefit, it affected the head, and caused a most copious scarlet erup- tion on the skin. — (c) Very copious effusions of blood alarm the patient; and although they frequently relieve the sthenic forms, yet, if often repeated, or occurring too largely in the asthenic varieties, they require to be moderated, or arrested. In the former states, general or local depletions will be the best means of removing them; but in the latter, or when they sink the vital energy, the terebinthinated draught and injection prescribed above (§ 90.), or the superacetate of lead, in draughts with acetic acid and laudanum, or in enemata; or the muriated tincture of iron in the infusion of quassia, by the mouth, or in clysters; or lime juice and opium, similarly prescribed; will generally prevent further discharge. — (d) Distressing flatulence and meteorismus will often be relieved, especially in the adynamic states, by a terebinthinated or an assnfoetida injection (F. 136.), and by the warm epithem; or by the infu- sion ofthe leaves of rue, employed as fomentations over the abdomen; or by the bruised macerated leaves applied warm to the same situation.— (e) Leipothymia or sinking, or even full syncope, may follow the efforts at evacuation—particularly if the 68 726 DYSENTERY — Consequences of Acute and Chronic patient get up to the night-stool, at an advanced, or in an adynamic state of the disease; and death may even take place from this circumstance, es- pecially in the scorbutic complication, or when the patient has been kept too low, or has been addicted to spirituous liquors. Restoratives, the supine posture, and the use ofthe bed-pan, should not be neglected in these cases. 117. C. (a) Prolapsus ani indicates severe irritation about the sigmoid flexure of the colon, and upper part of the rectum, and requires the careful replacement of the part, local depletions from the sacrum, astringent fomentations with opium to the anus, astringent lotions, and in- jections with an urethra syringe, especially if the rectum be ulcerated; small injections ofthe dilute black wash, if sloughing of the bowel be suspect- ed; and the belladonna plaster over the sacrum, or above the pubis, in order to remove the spasm of the muscular coats of the intestine. When this symptom occurs in chronic dysentery, we may infer the existence of ulceration. In such cases, injections of a solution of nitrate of silver will give permanent relief. — (6) Excoriations about the anus often occur, in all the forms of the disease, but most frequently in the hepatic complication, and require warm anodyne fomentations and poul- tices ; small narcotic injections; and ointments with opium and mineral astringents, as the sul- phate of zinc or the acetate of lead.—(c) Abscess in the vicinity of the anus should be treated at first by local depletions and cooling discutient applications; and if these fail, by warm poultices, and early external openings, in order to prevent internal fistula. If the suppurating part assume an unhealthy aspect, injections with the dilute disinfecting fluid, and a tonic constitutional treat- ment, should be adopted.—(d) Ulceration in the bowels, of a sloughing kind (§54.), is a very unfavourable occurrence in the acute forms, for which a tonic and an emollient treatment—the internal use of the chlorates with opiates, and mucilages, clysters of the same description, and the other measures directed for the malignant variety (§89.)—should be employed.—The ulce- ration that takes place in the progress of the chronic form ought to be treated by the remedies recommended for the obstinate states of that form (§ 105, 106.). 118. iv. Of certain Consequences of Acute andChronicDysentery.—A. (a) In the acute varieties, and occasionally in the chron- ic, the extension of inflammation, with or without previous ulceration, from the internal to the exter- nal surface of the bowels, or to the omentum, or mesentery, is one of the most dangerous results; and requires very decided treatment, as soon as the symptoms of this change (§55.) appear. Gen- eral or local depletion, if the state of the circula- tion and of the constitutional affection permit either or both, should be practised; a full dose of calomel, camphor, and opium being exhibited immediately afterwards. These may be followed in a few hours by the terebinthinated draught, or enema, or by both; but more especially by the warm turpentine epithem (§89.), which ought to be repeated until the peritoneal inflammation is sub- dued. Nothing short of these means, promptly practised, will, in such cases, save the patient; but these will sometimes be successful, if proper- ly employed, and not left to ignorant or careless persons. — (6) Adhesions of various parts of the serous surfaces sometimes remain after these at- tacks; as shown upon dissection of cases that have been carried off a long time subsequently by other diseases. The signs of this sequela are very obscure and uncertain. But 1 believe, that these adhesions will gradually diminish, and ulti- mately al.nost disappear, if we succeed in restor- ing the natural functions to a healthy state; all adventitious productions being removed by a due manifestation of the vital energies in the assimilat- ing and absorbing organs; and by derivation to, and counter-irritation in, distant parts. Either with, or without, the effusion of lymph necessary to these adhesions, a copious effusion of serum into the peritoneal cavity may take place, the dysenteric affection being suppressed, or very rarely persisting. This occurrence is most fre- quent when there is coexistent disease of the liver, or when the dyseutery has followed fevers. The -treatment, in such cases, must be much the same as that directed in Dropsy ofthe Abdomen. The application to the abdominal surface, twice daily, of about a drachm of an ointment consist- ing of from six to twelve grains of veratria to an ounce of prepared lard, as first recommended by M. Mag en die, and very recently adopted in this country, promises to be extremely beneficial, as being more especially appropriate, in dropsy occurring in these circumstances. 119. B. Contractions or strictures ofthe colon are among the most unfavourable changes, attend- ing the advanced stages of the chronic disease, or remaining as its sequela. It is important, in respect both of the diagnosis and treatment, to form some idea, although we cannot often be certain, of their existence during life. Yet I have seen the diagnosis fully established, in some in- stances, by rational inferences from the pheno- mena of the case. The use of bougies, for the purposes of diagnosis or cure, is entirely out of the question: the legitimate exercise of medical science is here only required. If there be great difficulty or impossibility of procuring full or fecu- lent stools, the patient not complaining of tenes- mus or the acute symptoms of dysentery; if the evacuations be scanty, or contain semi-dissolved faeces, with shreds of white mucus or of albu- minous exudation, and if they be preceded by an uneasy sensation in the course of the colon, with that of load or fulness about the caecum and right hypochondrium, or between the epigastrium and umbilicus; if there be distension of the abdomen, with flatulent eructations and a foul or feculent odour of the breath; if an injection cannot be fully thrown up, or if it return immediately, or before the last part is thrown up, although the pipe is fully introduced and carefully guarded; and particularly if these symptoms occur in an advanced stage of the chronic disease, or in persons who have had previous attacks ; then stricture in the left and sigmoid flexures, or even in the transverse arch, should be dreaded. In such cases, the patient will occasionally complain of a sense of tearing, scraping, gnawing, or of dragging in some part of the colon, previously to the operation of the bowels ; the regions of the cascum and ascending colon being hard and tumefied. 120. The chief objects in these cases are to preserve the contents of the large bowels in a DYSENTERY — Treatment advised by Authors. 737 fluid state, and prevent thereby the accumulation of faecal matters above the stricture, and the con- sequent irritation and distention; endeavouring, at the same time, to subdue the chronic inflam- mation and ulceration frequently existing in the strictured part. These intentions are to be ful- filled by gentle and cooling laxatives; by refri- gerants with anodynes and emollients, and by injections of a similar kind, slowly and carefully thrown up by the improved apparatus. Gentle friction, also, of the abdomen, with oleaginous or antispasmodic liniments, following the exhi- bition of these medicines, will also be serviceable. As to the particular remedies that may be em- ployed, the supertart. of potash with borax, or with magnesia; soda tartarizata; manna; olive oil, or oil of almonds, either alone, or with sweet castor oil; ipecacuanha with soap, small doses of blue pill or hydrarg. cum creta, and extract of hyoscyamus or of conium; the nitrate of potash with subcarbonate of soda and small doses of camphor; the confection of senna with sulphur, and cream of tartar; the decoctum liniin enemata with olive oil, or with borax; the common soap injection; the emplastrum ammoniaci cum hy- drarg. either alone, or with extract of belladonna, placed on the abdomen; or the linimentum hy- drargyri, with the linimentum saponis cum opio, and the linimentum camphoraecompositum, rubbed assiduously on this part; or external irritation of it by F. 311., or by citron oil; and a regulated farinaceous diet; have appeared to me the most successful remedies. Aloetic, saline, resinous, or irritating cathartics are obviously injurious. During this treatment, febrile excitement of the system should be guarded against, and removed by cooling diaphoretics. The occurrence of stric- ture in the rectum, as a sequela of chronic dy- sentery, is not infrequent, and should be treated upon the same principles and in the manner ex- plained in the article Rectum. 121. v. Notices of Methods of Cure and Remedies recommended by Writers.—In the treatment of no other disease, perhaps, has the baneful influence of exclusive medical doctrine been more fully exerted than in that of dysentery. This is fully evinced by the much less rational measures very generally employed, towards the end ofthe last century and at the commencement of this, wherever the theory of Brown was adopted.—A. Vascular depletions have been di- rected in dysentery from the earlier periods of medical history. They were recommended by A etius,Alexander, andRhazes; and by Go- n.iott(Ergo Dys. Phlebotomia. Paris, 1604.), Ri- verius,.Prosper Alpinus, Lespicier, Bo- tallus, Sydenham, Ellain, Zacutus, and many other writers ofthe sixteenth and seventeenth centuries; but had fallen into disuse, when Dr. J kCKSox andDr.WHYTE(Med.and Phys.Journ. vol. ii. p. 288.) revived the practice. During the Peninsular campaigns, general and local bleeding were freely employed by Drs. Somers, Fergu- son, Forbes, and other physicians of the British army. Indeed, it had never been altogether neglected by judicious practitioners during the last century, notwithstanding the injurious in- fluence of theory upon medical observation and practice; for we find it directed by Hillary, Akenside, Cleghorn, Pringle, Baker, Stoll, M'Grigor, Stc, and strenuously conten- ded for by JuNCKER(jDe Util. Venasect. in Dys. Hal. 1770.) in the early stages of the inflammatory disease. From what has been stated above, it is ap- parent that bloodletting, although applicable to cer- tain forms of dysentery, should be employed with much discrimination, and with due reference to the exciting causes, and to the prevailing epidemic constitution. This is well illustrated by its in- jurious effects in the asthenic forms; especially those proceeding from depressing causes and con- taminating sources; and by the history of dysen- teric epidemics (§ 29.). Mr. Bacot states that, when the malady was consequent upon fever, in the Peninsula, or arose from the same exciting causes, bleeding could seldom be borne. It would also appear, that from 1817 to 1827, during which period the seasons were tolerably regular and the summers dry and warm, this disease was attended by more or less of the in- flammatory diathesis; and that, from this latter date, when they became less regular and much more wet and cold, it has assumed more of the asthenic characters. The application of leeches to the anus, advised by Neumann, Hunnius, and many French writers, is often productive of benefit; but irritable sores, owing to the excre- tions coming in contact with the bites, are apt to follow. 122. B. Evacuants.—(a) Emetics are extolled by some writers, and considered injurious by others. The circumstances in which they may be employed (§ 92. 115.) have already been pointed out. They are certainly more beneficial ia some seasons and epidemics than in others; as, indeed, admitted by Chomel (Ergo Dysent. Vomitus. Paris,1698.), Fischer, Goeden, Michaelis, and'ScHMiDT (De Emet. Usu in Dysent. Jenae, 1803.), and Hunnius(Horn's Archiv. 1811. p. 151.) ,who are amongst the most strenuous believers in their efficacy. Hippocrates directs early re- course to be had to them. Cleghorn advises them in the bilious form : Wendelstadt in the same variety, or when the disease is complicated with rheumatism; and he prescribes diaphoretics and opium after their operation. Stoll very justly considers them most appropriate where there are little fever, and no constant pain or tenderness in the abdomen. In these cases, they generally promote diaphoresis, especially if opiates be given soon afterwards. As to the choice of emetics, some difference exists. Antimonials are preferred by Pringlf^-EV-Zmi. Med. Essays, vol. v. art. 15.), Baker, Adair, and Saunders; and ipecacuanha by Hargens,Weber,Anne sle y, and the great majority ofthe most recent writers. Dr.WRiGHT found ipecacuanha emetics,followed in succession by cream of tartar and castor oil; afterwards by Dover's powder, as soon as the digestive tube was evacuated; and, lastly, by cinchona or cascarilla; the most successful method in West Indian dysentery. 123. (b) Purgatives, generally of a mild de- scription, are directed by Du Brevil, J. Hunt- er, Lombard, Muller and Hesse (De Usu Evacuantiumin Dys. Jenae, 1800.). Sydenham prescribes those of an active kind, after bleeding and a full dose of laudanum. Jackson and Annesley adopt a nearly si mil ar practice. Hun- nius and Wendelstadt prefer laxatives, or mild and cooling purgatives, and consider them most serviceable in the bilious variety; whilst 728 DYSENTERY — Treatment advised bt Authors. Lind, Vogel, Thomann, Weber, and Neu- mann believe all purgatives injurious, and advise only the gentlest oleaginous laxatives. The cir- cumstances in which these medicines are most appropriate will be apparent from what has been stated above; as well as those which should be se- lected. Calomel is preferred by Jackson, Ball- ingall, Bampfield, and Annesley, when assisted in its purgative operation by other medi- cines, either combined with it, or given subsequent- ly. Sulphur is recommended as a laxative by Wedekind and Lance (Miscel. Verit. p. 30.); and certainly full doses of the precipitated sulphur, with one or two drachms of cream of tartar; or these with confect. sennas, in the form of electuary, are amongst the gentlest and most certain aperients that can be exhibited, in an advanced stage ofthe acute, or in the chronic disease; and may be given every two or three hours, until the effect is produced. The neutral salts are, in general, not so serviceable as the laxative oils, although Clarke, Balmain, and Mursinna are favour- able to the use of the sulphate of soda. Stoll recommends the saline aperients only in the bilious variety; and anodynes after their oper- tion; and several writers extol them when conjoin- ed with antimonials. The supertartrate and tar- trate of potash, or the soda tartarizata, are, upon the whole, the most serviceable of this class of purgatives. The supertartrate of potash, finely- levigated, and given to the extent of three or four drachms every six hours, in the form of electuary, with the pulp of tamarinds and syrup of ginger, will often open the bowels and procure the ex- cretion of bile, when other means fail. The practice is recommended by Selle(Z)« Curandis Morbis, fyc. p. 157.), and was found to succeed in some hopeless cases by Dr. Cheyne. It is the more efficacious after the exhibition of mer- curials; and, when the substance of the liver is acutely affected, may be depended upon as an appropriate refrigerant purgative. But, in or- dinary circumstances, there can be no doubt of the propriety ofthe decision of Cullen, Bang, Tode, Clark, and Piderit, in favour of olea- ginous laxatives given by the mouth, and in muci- laginous enemata. When we suspect, from the existence of scybala, or the appearance of the stools, or from fulness or hardness in the course of the colon, the accumulation of faecal matters in the cells of this bowel, the oleaginous draught j prescribed above (§ 83.) may be exhibited; or | the following pills may be given every two hours until a full evacuation is procured. No 203. R Scammoniae, Pulv. Rhei (vel Pulv. Jalap.), ba. gr. ij.; Potassae Suiphatis gr. iv.; tere probe simul, et adde Olei aut Syrupi q. s. ut fiant Pilulae duae. 124. (c) Enemata are amongst the most effica- cious means for either the evacuation of morbid matters, or the removal of the diseased action going on in the large bowels, or both. Those with the laxative and emollient oils are preferred by Celsus, Cullen, Bang, Horn,Radema- cher, and some others, when the first intention requires to be fulfilled; and to these substances may be added laudanum or hyoscyamus, accor- ding to circumstances. Amylaceous, emollient, or mucilaginous injections, with or without anodynes, are directed by Hippocrates, Alexander, Pa-ulus, Lind, Schlegel, Duncan, Neu- mann, Thomann, &c, chiefly with the second of these intentions. Small acetous clysters with opium are prescribed byVANDER He yde.Birn- stiel, and Bruning; decoction of linseed with laudanum, by Celsus, Clark, and Horn; de- coction of quince seeds, by Wendt; the decoction ofthe root of marsh mallows, by Paulus ^Egi- neta, andEcKER; milk, by Celsus, Alexan- der, and Forestus (lib. xxii. obs. 36.); and milk with theriaca, in the acute varieties, and with Venice turpentine, in the chronic, by Sydenham. Injections, as directed in the foregoing sections, should have strict reference to the state and stage of disease, and not be bulky. Hunnius considers large enemata injurious; they are very seldom long retained. Many substances, besides those now mentioned, may be thus administered; especially in the chronic states. Galen, and the Arabian physicians, exhibited nearly all the vegetable and mineral astringents, the anodynes, and even the escharotics, as the preparations of arsenic and copper, in this way. Dr. Jack son advises a weak solution of corrosive sublimate, with myrrh, and demulcents; and Mr. Annesley, the black or yellow wash, to be thrown up in enemata, in the chronic complaint. 125. C.Emollients and Demulcents are baneficial, not only in themselves, prescribed in the form of draught or injection, but also as the vehicles of more active substances. They constitute one of the chief means employed by Hippocrates in dysentery. Several oils are exhibited in this manner, either in the state of emulsion, or on the surface of other fluids. Linseed oil is preferred by Ruland (Curat. Erup. c. iv. n. 40.); al- mond oil, by Heuermann ; and sweet oil, by nu- merous writers. This last, in sufficiently large quantity, is one of the most efficacious remedies that can be administered as an enema. Mucila- ges, prepared chiefly from the gums, either alone (Gilibert, Advers. Pract. Prim. p. 417.); or with absorbents and opium (Pfenmnger and Staub); the decoctions of marsh mallows or of the common mallow(PAULUS,KoRTtM,EcKEn), drunk warm, in large quantity; saleb (Weber and Hargens); and the decoction of the Cara- geen moss, or of Iceland moss (Hargens, 1. c. and Herz, Briefe, b. ii. n. 2.); are useful medi- cines. 126. D. Anodynes, especially after vascular depletions where they are required, and alvine evacuations, are very generally recommended. —(a) Opium is the most to be depended on, and the most generally appropriate in some combin- ation or other, according to the intentions to be fulfilled. If its sedative effect chiefly be desired, and if inflammatory fever be present, it may be given in doses of from one to four grains, either alone or with nitre, or with antimonials, as di- rected by Blane, Himly, Jaw a ndt, Cheyne, Neumann, and Horn (Arcluv. b. vi. p. 103. et seq.). When it is desirable to procure a diapho- retic operation, it is best conjoined with ipeca- cuanha (Cardin, Muller, &c), or small doses of camphor and nitre; or in the state of laudanum, with considerable quantity of the spiritus aetheris nitrici, or with other diaphoretics (Hinze, Jack- son, &c), especially in the asthenic forms. If the biliary secretion be scanty, the liver not being actively diseased; or if the intention be to excite salivation; opium may be conjoined with mode- rate doses of calomel, and given every four or DYSENTERY — Trf. atme six hours, as directed by J. Johnson, Leiden- frost, Renton, and others—particularly in the sub-acute and chronic states. If the powers of life be depressed, and the circulating and secreted fluid vitiated, it will be necessary to exhibit it with tonics and antiseptics (Morton, Wede- kind, &c), as cinchona, the chlorates, &c; and with astringents (Riedlin), when the evacu- ations are profuse, the digestive mucous surface relaxed, or the disease chronic. Consbruck con- siders opiates injurious, unless preceded by emetics; and Sydenham, Mursinna* and others, either premise evacuations, or alternate them with an- odynes. The opinion of Wendelstadt, that opium, as well as astringents, are injurious in the bilious variety, until morbid secretions are evacuated, is judicious, and may be extended to most forms of the disease. In the nervous or typhoid variety, they should be given with great circumspection. Morton found that, when mainly depended on, in the epidemic of 1666, they augmented the exhaustion and muttering delirium frequently attending it. Opium, in sup- positories (Batman, &c), and in liniments rub- bed on the abdomen, or externally in other forms (Hargens and Thomann), has been already recommended in various states of the malady. 127. (b) Amongst those substances which act most energetically in removing spasm of the intestinal fibres, and diminishing morbid sensi- bility, hyoscyamus, belladonna, and tobacco, are the most deserving of notice. Hyoscyamus is re- commended by Matthdi, Withering, and Hunnius; and, in the acute and febrile states of the disease, may be exhibited in the same manner and forms of combination as opium. The recent juice of belladonna is praised by Gesner (Hal- ler's Biblioth. Med. Pract. vol. ii. p. 55.), and Ziegler (Beobachtung. p. 35.); but the powder of the root, and the extract of this plant, are equally efficacious when properly preserved. A strong infusion of tobacco is prescribed as a fo- mentation to the abdomen, by Drs. Graves and O'Beirne. These narcotics are appropriate only to the early stages of the sthenic states of the disease, and require much discrimination and caution. The prussic add, with camphor, ipeca- cuanha, and mucilages, is of benefit when judi- ciously prescribed. 128. E. Diaphoretics are extremely beneficial in the early stages of the disease. Those of a cooling and relaxing kind are most suitable to the sthenic forms, and such as are warm and ex- citing in the adynamic states.— (a) Antimonials are preferred by Pringle, Sims, Fischer, Ba- ker, Vogel, Adair, Richter, and Hufe- land; whilst Heuermann (Bemerk. b. i. p. 184.) considers them injurious,— an inference, which I believe to be correct as respects their ex- hibition in the advanced stages, or in the asthenic states. Of these preparations, the most service- able is James's powder, given with calomel, or with calomel and opium in the first stage. Liquor ammonia acetatis, with mucilages, emollients, and opiates (Hargens); or with small doses of cam- phor and nitre, and either with (Richter and Saunders) or without anodynes, is more gene- rally appropriate; and, in persons who have been addicted to spirituous liquors, or in the asthenic forms, with camphor mixture, the spiritus am- monia; aTomatiouS) or the spiritus atheris nittid NT ADVISED BY AUTHORS. 729 and laudanum, is very beneficial. The infusions of serpentaria or of arnica, either alone, or with liquor ammonias acetatis, or with camphor and opium, are indicated chiefly in the malignant or nervous varieties, or in the advanced stages of the other asthenic forms. The infusion or powder of the root of arnica (Michaelis, Collin, Birnstiel, and Fischer), may be employed in similar combinations and states of the disease, as advised by Richter. Stoll (Rat. Med. vol. ii. p. 421.) recommends it after emetics, depletions, and evacuants, in the acute; and in the chronic complaint. Ipecacuanha is, however, the most certain in its effects, when combined with opium, and the most to be depended upon, in arresting the train of morbid actions. The injunction of Sir G. Blane, to have recourse to diaphoretics after evacuations have been procured, should not be overlooked.—(b) The importance of restoring the functions of the skin has been duly estimated by Gruber, Jackson, Neumann, Vogler, and Schlegel, and should not be confided to in- ternal remedies merely. Tepid or slightly warm baths, in the highly inflammatory states, and warm baths (Blane, Horn, Richter, Konig, Go- eden, &c), or baths with aromatic and stimula- ting herbs infused in the water (Thomann, Ann. ad 1800, p. 237.) are also important means. Va- pour baths, and the application oi dry heat(ilT.is- ter,Vogler, andHARGENS,) are also deserving of notice. Frictions ofthe surface, or, as Prosper Alpinus and others advise, frictions with sweet oil, upon removal from the bath to a warm bed; and the internal use of diaphoretic diluents, are useful adjuvants.— (c) Warm poultices (An- nesley and Author) and epithems or foment- ations frequently applied to the abdomen, as directed by Alex a nder, Rive rius,Brunner, Stoll, Richter, &c, are often serviceable, when they are so managed as not to wet the bed'- clothes. Warm cataplasms of aromatic and anti- spasmodic herbs, &c, are praised by Heister, Blanchard, Thomann, Bruning, Klinge, (in Hufeland, Journ. der Pr. Arzneyk b. vi. p. 900.), Hinze, (Horn's Archiv. b. iv. p. 516.), Goeden (Ibid. Mart. 1812, p. 331.), and Horn (Ibid. b. vi. p. 263.). These also act as derivatives, as well as diaphoretics. 129. F. External derivation is very generally prescribed. Moseley and Matthsi recom- mend it chiefly in the complication with rheuma- tism, for which Paulizk y (Beobachtung. st. ii. n. 1.), directs blisters to the thighs; where, also, tbey are generally ordered to be applied by Muller, Ecker, and Amelung. Schlegel, Lind, Stoll, Blane, Fischer, Mursinna, Neu- mann, and Annesley advise large blisters to the abdomen; and Hunnius to the sacrum; whilst other writers think that they increase the dysuria. Sinapisms are noticed by Blane and Fischer; and camphorated liniments rubbed on the abdomen, by Lind. These are less rapid in their effects, and much less efficacious, than the turpentine epithem described above (§ 89.), or friction with croton oil, either of which may be also applied to the insides of the thighs and legs in urgent cases. 130. G. Astringents form a principal part of the means employed in dysentery by Galen and the Arabian physicians. Various substances of this kind are recommended. Dr.WRiGHT advises dtric acid and common salt, which are often of 730 DYSENTERY — Treatment advised it Authors. much service either with or without opium, espe- cially in the asthenic states, and as they occur in the dark races. Goeden (in Horn's Archiv. Mart. 1812, p. 284. and 323.), prescribes tartaric acid with refrigerants, and opium ; Bang, sulphuric acid with mucilage; Annesley, the nitro-muri- atic acids, with anodynes ; and M'Grigor and Hove,nitric add with opium; this last being chief- ly appropriate to chronic cases, and those associa- ted with disease or the collatitious viscera. Birn- stiel directs alum conjoined with camphor ; Loos (Horn's Archiv. Jan. 1810, p. 193.) alum with tormentilla root; Hunnius, Michaelis (Hufeland, Journ. der Pr. Arzneyk. h. vi. p. 280.), and Hargens (Ibid. b. vii. p. 137.), alum with mucilages, opium, &c, chiefly in the chronic and atonic states; Moseley and Jack- son, alum with sulphate of zinc, by the mouth and injections ; and Adair, alum with sperma- ceti, or gum, opium, and aromatics, in epidemic dysentery occurring among negroes. Lime water with milk, or with mucilages, is praised by Grainger, Brefeld, and Lange ; but is most serviceable in the chronic and asthenic states, and in the form of enema; in which cases, various other astringents are recommended, especially after mor- bid matters are evacuated. In this manner the preparations oi catechu are directed by Brande (Tode's Med. Journ. h. x. n. l.)and others; kino, by Weber ; hamatoxylon with cinnamon and other aromatics, by Pringle and Wendt; the tormentilla root, by Hoffmann ; the lythrum salicaria, by Quarin andGARDANE; the root of the ledum palustre, by BioRNi.uND;6e iv. p. 33. (Epidem c.)—Compagny, in Ibid. t. xvii. p. 295. (Endemic.)—L. J. Schmidtmann, Summa Observat. Med. kc. t. i. cap. x. p. 176.—Fraisse, Rev. Med. t. iw. 1825, p. 53.—L. Frank, De Pesta Dysenterica, kc. 8vo. Vien. 1820.—Chisholm, Climate and Dis. of Trop. Coun- tries, 8vo. Lond. 1822, p. 54.—Bampfe/d, On Tropica! Dys. particularly as it occurs in the East Indies, and on Scorbutic Dys. kc. 8vo. Lond. 1823.—M. Good, Study of Med., by Cooper, vol. ii. p. 595.—Jones, in Medico Chirurg. Review, vol. iii. p. 272. (Typhoid and infectious in crew of ships of war.)—J. A. F. Ozanum, Histoire Mtd. des Maladies Epi- demiques, Sic. t. iv. p. 90 —J. Johnson, On the Influence of Tropic 1 Climates on Europ. Constitut. kc. 4th edit. p. 225. —P. Vignes, Traite Complet de la Dys. et la Diarrh. &c. 8vo. Paris 1825.—Renton, in Trans, of Edin. Mel. and Chirursj. Soc. vol. ii. p. 376.—Elliotson, in Trans, of Med. and Chimrg. Soc. vol. xiii. p. 451.—Baillie, Lect. and Ob- serv. on Med. Lond. 1823.—J. Annesley, Sketches of the most Preval. Diseases of India, kc 8vo. 2d edit. Lond. 18.11.—J. Annesley and Author, Researches into the Causes, Nat. and Treat, of Dis. of India, and of Warm Climates, kc. 4lo. Lond. 1828, vol. ii. passim.—Bright, Reports of Medi cal Cases, &c. 4to. vol. i. Lond. 1827, p. 176.—J. Aber- crombie, Path, and Pract. Researches on Dis. ofthe Abdom- inal Viscera, &c. 2d edit. Edin. 1830, p. 236. et seq.— Kreyssig, in Encyclopadisches Worterbuch d. Medicinisch. Wissensch. &c. b. ix. p. 627.—A. Bompard, Traite des Mai. des Vok-s Digestivy, kc. 8vo. Paris, 1829, p. 128.—Walsh, in Trans, of Med. and Chirurg Society of Edin. vol. iii. p. 512. (On the Scorbutic Dys. in the Burmese War.)—W. Twi ing, On large Doses of Ipecacuanha in Dys., in Trans. of Med. and Phys. Soc. of Calcutta, vol. iv. p. 170.; and On the Pathol, and Treat, of the most important Dis. of Bengal, 8,o. Calcutta, 1832, p. 1. DYSMENORRHEA. See Menstruation. DYSPHAGIA. See Deglutition, Diffi- cult. DYSPNCEA. See Respiration, &c. DYSURIA. See Urine, &c. EAR—Nervous Affections of the. 1. Certain diseases of themr will be here considered; which, although sometimes attended by disorder of hearing; and often terminating in impairment, or loss of this sense; are not neces- sarily accompanied by either. — In the article Hearing, the affections of this function will be viewed with reference to the lesions producing them, seated in different parts ofthe organ. I. Noises in the Ear. Syn.—Tinnitus, Susur- rus, Sonitus, Sibilus, Syrigmus, Bombus, Au- rium, Auct. Paracusis illusoria, Good. Das OhrentOnen, Ohrenklingen, Ger. Tintement, Bourdonnement de I'Oreille, Fr. Singing in the Ear. Classif.— 4. Class, 2. Order (Good).— I. Class, IV. Order (Author). 2. Defin.—A sense of ringing, whizzing, or beating sounds in one or both ears, without ex- ternal causes. 3. i. These sounds vary in their characters. They are sometimes sharp, shrill, ringing, and suc- cessive; occasionally whizzing, roaring, acute, and continuous; and in other instances, beating or throbbing. They may be recurrent or intermittent, or devoid even of remissions, and be heard either in one or in both ears. M. Itard—the highest authority on diseases of the ear — divides them into,—1st, the false, or those which have no ex- istence whatever; and, 2nd, the true, or such as are seated in the interior of the head, or of the ear, but without being caused by external sonorous bodies. Tinnitus aurium is most frequently attend- ed by a slight degree of deafness, which, in some cases, it produces, and in others is merely coinci- dent with it. (a) True tinnitus may proceed from — a. cerebral plethora, congestion, or determina- tion ; — p. the impeded or obstructed return of blood from parts within the head; — and, y. me- chanical obstacle to the free circulation of air in the different compartments of the ear; but without completely preventing its entrance, for then the noise would be replaced by simple deafness. When the noises depend upon the state of the cerebral circulation, they are generally beating, heavy, hissing, or whizzing; frequently correspond with the pulsation of the carotids, which also is often strong; and are arrested by pressure of these ves- sels, (b) False tinnitus is—«. idiopathic, as when a very loud noise has injured the function of the auditory nerve; and, p. symptomatic, when allied to some nervous affection, often unappreciable in respect either of its cause or of its nature, or sym- pathetic of disorders of some other organs. Thus, this affection often attends indigestion, and hypo- chondriasis, especially in persons devoted to pro- longed and exhausting mental exertions; sometimes debility or hysteria, particularly in delicate females, who have suffered from excessive discharges, or who are addicted to venereal indulgences or ma- nustupratio ; and occasionally disorders of the prima via, as worms, torpid states of the colon, &c. In this variety, the noises are, in some cases, of a very unusual and even singular kind; and in hypochondriacal, nervous, or melancholic persons, give rise to various fancies or even hallucinations. In the case of a lady, for whom I was lately con- sulted at the same time with two other physicians, and who complained of noises in the ears after having suffered in her general health from too frequent returns of the catemenia, in excessive quantity, there gradually arose in the mind of the patient, an idea that persons were engaged whis- pering behind her; and ultimately it took so firm a possession of her mind, that it amounted to an hallucination, influencing both her judgment and her actions. 4. ii. Noises in the ears are most frequently caused by interruption to the free circulation of air through the Eustachian tube. Hence they are common attendants on catarrhs, and on enlarge- 736 EARACHE — Pathology—Causes or. ment of the glands, &c. in the vicinity ofthe tube; and are often produced by currents of cold air fall- ing on one side of the head or directed towards the ear, as by travelling in an open carriage, or with a carriage window open; or by having the hair cut, when abundant, in cold weather. When caused by partial obstruction of the eustachian tube, a loud noise or crack is heard upon yawning; and the sounds often cease, or are diminished for some time afterwards. They are frequently a troublesome symptom during convalescence from fevers ; and are sometimes attendant upon rheu- matic affections ofthe head or neck; in both which circumstances, they are probably dependent on morbid sensibility of the auditory nerves, or on determination of blood to the head, or on both. Mr. Tod imputes them chiefly to a faulty state of the secretions of the ear, in respect either of qual- ity or quantity; Mr. Buchannan, principally to an imperfect secretion of cerumen. Their depen- dence upon derangements within the head, as well as upon affections of distant organs, should always be kept in mind, whilst investigating their nature and relations; and hence the propriety of viewing them in the comprehensive manner adopted by M. Itard. 5. iii. Treatment.— The ancients, especially Celsus, paid considerable attention to this affec- tion ; many of these remedies are active and ap- propriate. It is obvious that the means of cure should be directed to the pathological conditions on which it depends. In the true tinnitus, especially when it is of a beating kind, vascular depletions should be prescribed. M. Itard has seen it in- stantly vanish upon opening the jugular vein. Ac- tive and continued purging, with due attention to the digestive organs, is also requisite in these cases. Symptomatic false tinnitus should be treated ac- cording to the nature and seat of the primary af- fection. When it is connected with rheumatism, Grapengiesser and Ritter advise having recourse to electricity or Galvanism. For the true nervous or diopathic affection, tonics, nervines, blisters behind the ears, stimulating gargles, and antispasmodics may be prescribed. Heister recommends in such cases fumigations ofthe ears with the vapour of a hot vinous infusion of rose- mary and lavender; M. Itard, fumigations with aether directed to the meatus, frictions ofthe scalp, and warm applications, with the view of promot- ing an abundant transpiration in this situation; and Mr. Buchannan, two drops of the mixture of equal parts of pyroligneous acid, spirit of sulphuric aether, and spirit of turpentine to be introduced into the ear. The digestive organs should be as- sisted by stomachics, aperients, or purgatives; and transpiration promoted by gentle diaphoretics, and moderate exercise in the open air. When tinnitus arises from cold, the same means, or those usual- ly resorted to in Catarrh, with attention to the state ofthe bowels, will be appropriate. Gargles also with the* muriate of ammonia, or nitrate of potash, or this latter and the sub-borate of Soda, will also be useful. In this form ofthe affection, little further should be attempted, unless it become chronic, from partial obstruction of the tube, or diminished secretion of cerumen, in which cases it is generally associated with some degree of deaf- ness, when it will require the treatment advised, in such circumstances, in the Article Hearing — diminution of, fyc. BlBLIoo. AND REFER.—Celsus, I. vi. c. 7, 8.—Aetius, Tetrabl. ii. Serm. ii. C. 18.—Paulus Atginata, 1. iii. r. 23. —Avicenna, Canon. 1. iii. fen. 4. Tract vol. i. c. 9.— Sclienk, De Tinnitu Aurium. Jena;, 1667.—Helbick, De Sonita et Tinuilu Aurium, Altd. 1699.—Finck nau, De Tinnitu Aurium. Re,'. 1706.—Hoffmann, De Audilus Vi tiis, Opera, vol. iii. obs. i. p. 243.—lantke, De Tinnitu Au- rium ejusdemq' e Speciebus. Altd. 1746.—Sauvages, Class VIII., Order IV. Nosol. Method.—Leidenfrost, De Tin. et Susurro Aurium. Duisb. 1784.—Doering, vol. i. p. 205.— Louis, Med. Comment, vol. iii. p. 52.—Wesener, De Susurro Aur. Duisb. 1785. — Grapengiesser, Versuche, p. ISO.— Ritter, in Hufeland, Journ. d. Pract. Heilk. b. xvii. st. iii. p. 40.—./. M. C. It aid, Traite des Mai. de 1'Oreille, itc. 8vo. Paris, 1821. t. ii. p. 14.—Andral, Diet, de Med t. xx. p. 425.—T. Buchannan, Illust.of Acoustic Surgerv, 8vo. Lond. 1825. p. 60.—D. Tod, The Anat. and Phys. ofthe Organ of Hearing, with Remarks on its Diseases, i.c. 8vo. Lond. 1832. p. 121. II. Earache. Syn.— Otalgia (from ou; cwroc, the ear, and a/.yivi, I pain); Ohrenschmerz, Ohrenzwang, Germ.; Otalgie, Fr. 6. Defin.— Violent pain, generally in one ear, suddenly supervening, and often abrupt- ly departing, without fever. 7. i. Earache is most frequently symptomatic of inflammation of the ear, or ofthe presence of foreign bodies, or of insects in the meatus, or even of congestion or inflammation within the head. It sometimes also attends inflammation of the pharynx, or of the tonsils-and fauces, or of the parotid gland ; and is occasionally consequent upon small-pox, scarlet fever, and erysipelas of the adjoining parts. More rarely it is idiopathic, or a purely nervous affection, seated either in the nervous filaments sent to the internal parts of the ear, or in that part of the facial nerve passing through the aqueduct of Fallopius, or in the filaments of the acoustic nerve, which seems the least probable seat. The idiopathic, or true nerv- ous otalgia, is at its maximum of intensity on its invasion ; and, unlike the pain attending otitis, does not gradually increase in severity, nor is it attended by throbbing, and inflammatory fever. Its duration is very uncertain. Sometimes it dis- appears abruptly in a very short time, occasion- ally being followed by neuralgic or rheumatic pains in some part of the face or head, or even in a remote part of the body — an occurrence fur- ther distinguishing it from otitis — and frequently again returning to the same ear, and very rarely to the other. When the pain is excessive, it often irradiates along the nervous filaments over the same side ofthe cranium, or ofthe face, or both, the eyes sometimes becoming i>ed and watery ; but it seldom or ever occasions delirium or con- vulsions (Itard), unless it be connected with inflammation of the internal ear, or is produced by insects or foreign bodies in the meatus. When, however, the pain proceeds from this latter cause — an occurrence which is not unfrequent, partic- ularly in children, and of which I have seen several instances amongst the poor and squalid — dangerous and repeated convulsions often super- vene. Noises in the ear, and often a slight deaf- ness, accompany otalgia; indicating the coinci- dence of extreme exaltation of sensibility in the parts composing the ear, with a diminished power of perceiving sounds; and evincing that the acous- tic nerves are not the seat of the exquisite pain that is felt. Like all nervous affections it is never constant in its course : it may be continued, or in- termittent; may recur several times, after irregu- lar intervals; or it may appear once and never return. EAR — Acute Inflammation of—Pathology. 737 8. ii. The Causes of earache are those of all other nervous affections. Otalgia is much more common in females than in males; and it some- times attends the early periods of pregnancy. It is often symptomatic of disorder in the prima via, and is frequently connected with rheumatism, par- ticularly of the face, head, or neck; as well as with facial neuralgia and toothache. M. Andral treated a case, in which it alternated with sciatic neuralgia. M. Fauchard records an instance where it long resisted all treatment, until a carious molar tooth on the same side as the affected ear was extracted; and Mr. Pettigrew, in the case of a lady suffering excruciating agony from this affection, directed the wisdom tooth to be drawn, which he correctly inferred to be its cause, and the pain was instantly abated. Various writers have seen otalgia consequent upon the disappear- ance of rheumatism and gout. A case following rheumatism occurred in my own practice ; and another, produced by a current of cold air falling on the ear. This last is, perhaps, one of its most frequent causes. Earache may exist for some time, and either excite, or be merely contingently follow- ed by, otitis, which, however, may have commenc- ed long before its usual signs were fully developed. 9. iii. Treatment.— If this affection hesymp- tomatic, the means of cure must be directed to the primary disease. (See Ear—Inflammation of.) If it arise from a foreign body, this should be extracted without greatly increasing the irrita- tion; but if that cannot be accomplished, it will be better to wait its spontaneous discharge by means of the increased secretion which will be occasioned. Insects may be dislodged by inject- ing a sufficient quantity of an emollient oil into the meatus ; or by introducing a small piece of sponge or cotton, with oil, by means of a probe. Infusion of tobacco, various other narcotics, and even acrid substances, have been directed to be employed for this purpose; but I believe that they may sometimes prove injurious,—an opinion also entertained by M. Itard. For the more obvi- ously nervous or idiopathic otalgia, the ancients recommend the injections of warm emollient or stimulating oils; or these conjoined with anodynes. CjElius Aurelianus advises tepid oil to be dropped into the ear, and wool to be stuffed into it; he also directs fomentations, poultices, scarifi- cations, and leeches, — remedies often service- able, and generally safe. M. Itard states, that he has seen opiates introduced into the meatus for this affection followed by cerebral symptoms : he therefore prescribes the injection of tepid emol- lients, such as milk, the decoction of march-mal- lows, &c.; means but little different from those mentioned by the authority just referred to. In addition to these, he recommends the mouth of a phial containing three drachms of Hoffmann's anodyne, and half an ounce of water, to be direct- ed to the meatus, the phial being kept immersed in warm water; and an abundant transpiration from the surface of- the head to be excited, by sponging it with warm water for a quarter of an hour, afterwards rubbing it for some time with warm flannel, and lastly covering it by an imper- meable or gummed silk cap. Blisters behind the ear, or on the temple, and medicines to promote the alvine secretions and excretions, are also suit- able. Dr. Lehman directs a mild purgative, and the introduction of cotton into the meatus, charged 62* with tincture of digitalis. Dr. Kennedy prescribes an emetic as early as possible in this affection; and after vascular depletion, if inflammatory action seem to be present. I found an active emetic almost immediately abate the excruciating pain, in the case of the wife of a celebrated author. After free vomiting, which may in some cases be promoted by the warm infusion of chamomile flowers, a dose of calomel, either with, or fol- lowed by, a purgative; and gentle diaphoretics; will be of much service. In every case, the state ofthe gums and teeth should be examined. Where the head is free from congestion, warm baths, vapour or fumigating baths, and narcotics with antispasmodics internally, may be tried. Tonics, especially the sulphate of quinine, the preparations of iron in large doses ; valerian, or serpentaria with cinchona; or an infusion of valerian with the ammoniated spirit of colchicum; may also be prescribed, more particularly if the otalgia be of an intermittent type, or of a rheumatic character, and if morbid secretions have been evacuated by an emetic and purgatives. In the rheumatic or gouty state of the complaint, the decoction or in- fusion of cinchona with valerian, the subcarbonate of soda, and the ammoniated spirit of colchicum, will be most efficacious. On the first indication of inflammatory action in the ear, or within the head, the jugular vein on the affected side should be opened, or other modes of depletion instituted, and active cathartics administered. Bibliog. and REFER.—Celsus, I. vi. c. 7.—Ccelius Au- relianus, Morb. Chron. 1. ii. cap. 3.—Hoffmann, De DolOre Otalgico, obs. 2, 3.; Opera, vol. ii. p. 338.—Vokkamar, De Otalgia. Alt. 1733.—Kultschmid, De Otalgia. Jena;, 1749. —Delius, Aincenit. Acad. dec. iv. n. 10.—Itard, in Diet des Sciences Medicales, t. xxxviii. p. 507., et op. cit.—Andral, Diet, de Med t. xvi. p. 53.—Kennedy, in Lond. Med. Re- pos. vol. xxv. p. 244.—G. F. Lehman, in the Amer. Journ. of Med. Sciences, vol. v. p. 34.—(See also the References to art. on Inflammation of the Ear.) EAR — Inflammation of the. Syn.— Otit- is; Empresma Otitis, Good. Ohrenentziin- dung, Germ. Otite, Fr. Classif.—3. Class, Diseases of the San- guineous Function; 2. Order, Inflamma- tions (Good). III. Class, I. Order (Author). 10. Defin.— Ingravescent pain in the ear, with tenderness on pressure, or on moving the lower jaw ; with inflammatory fever, and fre- quently impaired or confused hearing. 11. Inflammation may affect both the external and internal ear at the same time; and it may commence in either, and be thus confined, or ex- tend to both. It assumes various grades of severity; its duration being equally indefinite. The more acute states ofthe disease will be first considered; and next, those which are chronic, and which, from being characterised by a discharge from the external meatus, have been called Otorrhaa. 12. I. Acute Inflammation of the Ear — Otitis Acutus —has been accurately observed only in modern times; and more especially by J. P. Frank, Itard, and Lallemand.—(a) Sometimes the external conduit or meatus is the chief seat of inflammation —External acute otitis. —(b) Frequently the cavity of the drum, with its dependencies, the membrane of the tympanum, Eustachian tube, and mastoid cells; or the inter- nal ear, strictly speaking — as the vestibule, the semicircular canals, and the cochlea; either sepa- rately or conjointly, is the seat of the disease,— 738 EAR — Acute Imflammation of—Symptoms. Internal acute otitis. These will be described j separately, but with reference to their mutual relations. 13. i. Symptoms.—A. Oi External Otitis.— Inflammation of the external conduit frequently commences with slight pain, or a sense of heat, or of intense itching or irritation, gradually in- creasing to an acute or distressing degree. It is sometimes lancinating, or is increased at intervals; and it occasionally gives rise to various nervous symptoms. In other cases, the disease runs its course without being attended by much pain. But pain is always augmented upon pressure; by the motions of the lower jaw; and by the contact of cold air, and too warm fluids. Hearing is also impaired or confused ; and noises are heard in the ear. Upon examining carefully the meatus, several of the changes about to be noticed (§17.) are observable. From a few hours to three or four days after the commencement ofthe symp- toms, a fluid begins to be discharged from the meatus, that is generally at first thin, limpid, or sanguinoleut; but gradually becomes thicker, and assumes puriform characters; being whitish, yel- lowish, or greenish ; inodorous, or foetid ; and sometimes so acrid as to irritate the part with which it remains for some time in contact. With the increase of the discharge, the pain usually abates, unless inflammation extends to the inner ear. Afterwards, as inflammation declines, the fluid passes into a consistent or caseous matter, that accumulates in the meatus, and requires to be removed; and is followed by a more abund- ant secretion of wax than usual. Occasionally, as the discharge from the interior of the meatus decreases, a serous exudation from behind the ear supervenes. 14. B. Internal Otitis is sometimes attended merely by local symptoms : but whenever the inflammation is very acute, and the pain great, more or less fever is present, with headach, watch- fulness, and disorder of the natural functions. The chief difference between the course of this and external otitis is contingent upon the parts of the internal or middle ear chiefly affected. Thus, the matters secreted by the inflamed surface of the cavity of the tympanum can be discharged externally only with great difficulty, owing to the extension of inflammation to the adjoining por- tion of the Eustachian tube, and its consequent obstruction; their retention giving rise to a most distressing sense of distension, with painful throb- bing, febrile reaction, and nervous disturbance. —a. Internal otitis often commences with severe headach or hemicrania; and an intense, acute, continued, and deep-seated pain, with clanging, loud, or beating noises, in the ear. These symp- toms become more severe, and are generally at- tended by heaviness in the head, and often with a sense of bursting or distension in the ear. The eyes are now injected and watery; the face anx- ious or red; the skin somewhat hot; the pulse frequent, but not full; the tongue loaded or white; and all the natural functions disordered. In some cases, particularly when the more interior parts are inflamed, it requires attention to connect the cerebral symptoms with their origin; but the pain is generally referred more especially to the in- ternal ear; is attended by severe tinnitus; and is increased on mastication, and on moving the bead, and on the least noise. In other instances, the pain is felt at the bottom ofthe meatus, which is seen, on examination, exempt from lesion; or in the mastoid process. Delirium, especially at night, often attends the complaint at its acme; or convulsions, in children. The fever often as- sumes a nervous or typhoid character, if the in- flammation do not readily terminate in resolution. The above may be called the first stage, iu the most severe cases : but those which are less violent, or sub-acute, or actively treated at the outset, subside partially in from twenty-four to forty-eight hours; and afterwards more slowly; the functions of the organ still remaining more or less impaired for some time, but without passing into the next stage. 15. 6. When the disease does not thus ter- minate in resolution, the products of inflamma- tion accumulate in the cavity of the drum and de- pendencies, and force their way externally, their appearance commencing the second stage. These matters may be discharged — a. through a spon- taneous perforation of the membrane of the drum; — p. along the Eustachian tube; and, y. through a fistulous opening in the mastoid apophysis. The first of these is the most common — its fre- quency being to that of the second in the pro- portion of six to one (Itard); and the third comparatively rare. The discharge by perfora- tion of the tympanum generally takes place sud- denly; a large quantity of matter being voided, as if an abcess had burst; and the patient experien- ces relief, which increases with the continuance of the evacuation. Sometimes the great consistence of the secretion prevents its passage through the opening in the membrane, and causes its reaccu- mulation in the cavity ; and occasionally the irritation and inflammation produced by it in the meatus, or the incrustation of it on this passage, obstructs this outlet, and has the effect now stated, with the consequences of prolonging or augment- ing both the local and general symptoms. It is necessary, therefore, to ascertain the permeability of the meatus, as well as that of the Eustachian tube, which most frequently is obstructed in these cases. This is to be done both by inspection of the external conduit, and by causing the patient to expire forcibly whilst the mouth and nose are shut. If the Eustachian tube be permeable, bub- bles of air mixed with the fluid will escape at the meatus. In the much less frequent cases of the discharge of the accumulated fluid along the Eustachian tube, a sensation is felt in the pos- terior fauces or throat, as if an abscess in one of the tonsils had burst; a sudden expectoration of a muco-puriform, sanious, or purulent matter taking place, and continuing, in smaller quantity, for some time afterwards, or returning after in- definite intervals. 16. C. From what has been stated, it is evi- dent that the inflammation may extend from the external to the internal ear; but rarely from the latter to the former, unless matter finds its way through the tympanum. The duration of the disease varies from two to thirty, or even forty, days: but the symptoms lose their severity be- fore a month is elapsed, and become chronic, generally in the form of otorrhaa, which may, however, follow a sub-acute or an originally slight or chronic affection. After acute otitis has terminated, as above (§ 14.) in resolution, or by the discharge of matter externally (§ 15.), hear- EAR — Chronic Inflam ing often remains impaired, owing to the lesions consequent upon it; and is either recovered after some time, or permanently diminished. These lesions are thickening ofthe cartilaginous parts of the conduit; permanent thickening of the skin or dermis of the meatus, and narrowing of its canal; thickening, opacity, or perforation of the mem- brane of the drum; loss of one or more of the small bones; and obstruction of the tube of Eus- tachius. Caries ofthe mastoid apophysis, and of the petrous portion ofthe temporal bone, with destruction of the internal organisation of the ear, and disease of the adjoining membranes and por- tions ofthe brain, may also be caused by internal otitis; sometimes at a period very remote from the first manifestation of disease in this organ. 17. ii. The structural Changes produced by acute otitis are, injection ofthe delicate dermis lining the auditory conduit, with more or less tu- mefaction, and entire or partial obliteration ofthe canal. Pustular formations, at first red, after whitish and filled with pus, are seen in the surface of this tissue, varying in size and number : some- times transparent vesicles are met with instead of these. The fluid contained in these pustules or vesicles either is absorbed, or escapes through their parietes, giving rise to ulcerations of variable depth and size. The lining of the meatus, when inflamed, presents a striking resemblance to an inflamed mucous membrane; and the fluid which it secretes undergoes the same changes as that pro- ceeding from an inflamed mucous tissue. Thus, in the slighter grades of iuflammation, a mucous fluid fills the meatus; in an advanced stage and grade, purulent matter is formed; and occasionally, in children, a membranous or albuminous exuda- tion forms upon the surface of the canal. The osseous parts of the internal ear are seldom af- fected excepting in otorrhoea; but the cartilaginous portion is not infrequently softened, or even per- forated, in the acute disease. In rare instances, the perforation takes place from without, owing to an abscess formed between the mastoid apo- physis, the angle of the jaw, and the conduit. The inflammation may be limited to the mucous membrane of the tympanum, and give rise to the collection of a mucous, serous, sanguinolent, pur- ulent, or curd-like fluid in the cavity. From the mucous surface of this cavity, inflammation may extend—a. to the surface of the Eustachian tube, causing obstruction of it, either by the diseased secretion, or by the temporary swelling of the inflamed part;—p. to the mastoid cells, producing tumefaction of the mastoid apophysis, and occa- sionally a fistulous opening through it;—y. to the membrane of the tympanum, which, often in a very short time, is softened and perforated, allow- ing the discharge of the matters collected in the cavity, sometimes with one or more of the de- stroyed small bones. II. Chronic Inflammation of the Ear — Chronic Otitis; Otorrhaa (from ov~, a>roc, the ear, and rQtw, I flow); Ohrenflus, Germ.; Otorrhee, Fr. 18. i. History, &c.—A discharge from the ears may be seated in the external, or in the inter- nal, ear, or in both; or may proceed from an ab- scess opening into the ear. It has been distinguished into—a. Mucous, or Catarrhal otorrhaa; and, b. Purulent otorrhaa, from the appearance of the discharge; the former often preceding the latter, cation of—Pathology. 739 which is much more serious, as being generally dependent upon caries of the bone. Otorrhoea is often a termination of acute otitis; but it i3 fre- quently a primary disease, and not preceded by any acute symptom, not even by pain; the dis- charge being the only phenomenon.—a. Mucous otorrhaa may be confined to the external ear, the lining membrane being either scarcely altered, or red, tumefied, covered with vegetations; or par- tially adherent, and the canal partially or altogeth- er obstructed' or obliterated. This species of otorrhoea is' most common among children of a delicate, lymphatic, or scrofulous constitution; frequently resisting treatment for years, and yet subsiding spontaneously, or disappearing at pu- berty. Serious symptoms seldom accompany it; but sometimes hearing is somewhat impaired. The discharge varies greatly in colour, odour, and quantity; but little importance need be attached to these variations. It is often scanty at one time, and copious at another; or even disappears for awhile, and returns in greater or less abun- dance. The obstructions already noticed (§ 15.) in respect of the discharge in acute otitis, also occasion this change. In some cases, the sudden interruption of the discharge may be followed by pathological phenomena in some other quarters. M. Itard has seen engorgements of the lymphatic glands of the neck, tumefaction of the testes, affections of the eyes, porriginous eruptions on the scalp, and dangerous diseases' of the brain, follow its disappearance. I have likewise seen the same results, as well as partial paralysis of the nerves of the same side of the face, in three instances, two of which were referred to Sir C. Bell, in illustration of the discoveries of this eminent physiologist. M. Lallemand has re- marked the alternation of otorrhoea with an attack of rheumatism, with catarrhus vesicae, and with Ieucorrhoea. Mucous otorrhoea may also be seated in the cavity ofthe drum : in this case, the mem- brane is perforated, and the symptoms are nearly the same as now described. 19. b. Purulent otorrhaa may, like the pre- ceding, but much more rarely, by the result of a porriginous inflammation of the lining membrane of the meatus; or the matter may, in the first instance, proceed, as stated above (§ 15.), from acute otitis, the tympanum having been spon- taneously perforated; and, owing to the access of air whilst it lodges in the cavity of the drum, mastoid cells, and other parts, become more and more acrid; inducing ulceration in the membrane lining these parts, and ultimately inflammation and caries of the osseous structure itself. As soon as these changes take place, the discharge is more sanious than purulent— or of a greyish tint, mixed with red; exhales a peculiar odour, and stains a silver probe of a bronze colour; ca- rious portions of bone being sometimes also de- tached at an advanced stage. The patient, in these cases, generally complains of a dull pain in the ear, extending over the side of the head; of impaired hearing; with dulness, and a heaviness of expression. The caries is, in most instances, as here stated, the consequence of the disease of the mucous membrane lining the several auditory carols; but it is also, although much more rarely, the primary disease. In both cases, the otorrhoea is idiopathic. Abscess formed in the brain may form a passage through the petrous bone, which 740 EAR — Inflammation of — Pathology- had become secondarily affected and destroyed; the caries being, in this case, symptomatic. This occurrence, however, seldom takes place. 20. The mastoid process is more frequently the seat of caries than any other part; and is, consequently, the source of purulent otorrhoea in most instances; disorganisation proceeding also most rapidly in this situation, which is painful and tender on pressure, the external parts being swollen and cedematous. After some time, the mastoid cells are perforated; the skin reddened; and an abscess forms, bursts, and, becomes fistu- lous. On injecting a fluid through the external opening, which is generally close behind the ear, it frequently escapes by the meatus, or the Eus- tachian tube. Instead of an opening in this situ- ation, the pus sometimes penetrates between the muscles attached to this process, and the abscess opens low in the side of the neck. The diagno- sis is then more difficult. In some instances, the carious mastoid apophysis is not perforated, but the pus collected in its cells is evacuated through the cavity of the tympanum and the external meatus. Occasionally the carious part of the process is gradually melted away in the sanio- puriform discharge, without any disease of the soft parts covering it; the gradual destruction of it causing the disappearance of the prominence it occasions. M. Lallemand, therefore, di- rects the comparative state of both mastoid re- gions to be examined in cases of purulent otorr- hoea. The bony parietes of the external audi- tory conduit is sometimes the seat of caries; but much more rarely than the preceding. The part of the petrous portion of the temporal bone, which contains the semicircular canals, is, ac- cording to Itard and Lallemand, that which is most frequently diseased after the mastoid process. In other cases, caries is seated in the parts forming the aqueduct of the cochlea, or the aqueduct of Fallopius; or, lastly and more rarely, the internal auditory canal. But if, in some instances, the disease is thus limited, it is not so in others; various portions of the osseous structure being either simultaneously or succes- sively attacked. The petrous portion may be altogether destroyed, and the adjoining bones also invaded, and more or less injured. M. Lallk- mand has seen, in the same case, caries of differ- ent parts of the temporal and of the occipital bones, and even of the first vertebra also. 21 a. Caries ofthe petrous portion of the tem- poral bone, in some one of the states now noticed, necessarily induces disease ofthe membranes, and frequently also of the brain.—(a) It sometimes happens, that acute cerebral disease suddenly su- pervenes during otorrhcea, and death quickly follows; the petrous bone being found carious upon dissection, and the membranes adjoining extensively inflamed; but the brain itself sound. — (b) In other cases the cerebral symptoms take place more slowly, or assume the char- acters of chronic meningitis or cerebritis (see Brain, § 160. et seq.); either partial separation of the dura mater, with or without adhesion of the two lamellae of the arachnoid, or softening of the brain, or abscess seated in the cerebral structure, or both these alterations of the membranes and brain, being found after death. These lesions are observed more frequently at the anterior, than at the posterior, aspect of the petrous bone. Sometimes, instead of this portion ofthe temporal bone, a large collection of pus communicating with the middle ear is only found. The abscess formed around, or in the vicinity of, the petrous bone, consecutively upon disease of this part, often makes its way externally to the meatus; a similar channel of evacuation also being formed, but much more rarely, when caries of this bone fol- lows the formation of cerebral abscess (Andral). 22. |*J. The Symptoms which indicate the ex- tension of disease from the ear to the brain, or its membranes, are nearly the same as characterise the idiopathic states of inflammation of these structures (Brain, § 146. et seq.), according to the acute and chronic states they may assume. Whilst the ear only is diseased, the pain in the head appears to proceed from the ear as its source; but when the parts within the head become affect- ed, the cerebral symptoms are most prominent, and often obscure or altogether mask the disease of the ear. If, at an advanced stage of chronic otitis, the discharge be suppressed, or even much diminished, these symptoms are very liable to come on in a very severe form; and if some time elapse between the disappearance ofthe one, and the su- pervention of the other, and if the history of the case be not attentively investigated, the disease of the ear may be altogether overlooked; and what is strictly a symptomatic affection ofthe brain, or its membranes, treated inappropriately as an idio- pathic seizure.—When inflammation extends to the parts within the head, the patient complains of a deep-seated, and often throbbing pain, to- wards one side, with heaviness of the eyes, stupor, and slight delirium. The pulse is small, sharp, and quick; the tongue furred; and the febrile symptoms, which are usually slight, increased in the evening. There are also tenderness ofthe scalp near the affected ear, so that the patient prefers to lie on the opposite side, thereby favouring the lodgment of the morbid secretion in the ear; and sometimes convulsions with paralysis. Dur- ing the progress of caries of the bony structure, even before the disease has extended to the mem- branes and brain, more especially when the pari- etes ofthe aqueductof Fallopius are implicated, neuralgic pains in the face, inflammation of the conjunctiva of the eye, convulsive motions, and ultimately paralysis, of the muscles of that side of the face, &c. take place, owing to lesion of the trunk ofthe facial nerve. Since attention was directed to these associations by Sir C. Bell, numerous cases illustrative of them have been ob- served by Lallemand, and others; and several have been seen by myself. 23. y. The duration of otorrhoea is most indefi- nite. It may continue for several weeks or many years; and may resist all means. Sometimes it dis- appears either spontaneously, or during medical treatment. In other cases it presents a somewhat intermittent form, continues long to do so, and ultimately terminates either favourably or fatally, as stated above. In two instances which termi- nated in this latter manner,—at upwards of forty years of age in the one, and about thirty in the other,—I ascertained that otorrhcea commenced in early childhood, and had continued, with vari- ous remissions and intermissions, to that age, when cerebral symptoms came on. In these prolonged cases, the discharge varies much in quantity. When the Eustachian tube is not. obstructed, it often EAR — Inflammaxioi passes into the throat, and discolours the sputum; or is at one time evacuated by this route, at another by the meatus. During catarrh or sore-throat, the symptoms are generally aggravated, chiefly in consequence of obstruction to the discharge of matter. 24. ii. The Prognosis of otorrhcea depends — 1st, on its cause,—thus the syphilitic is much less dangerous than the scrofulous disease; — 2d, on the nature ofthe discharge, —-the puriform be- ing much more unfavourable than the mucous; — 3d, on the age,—it being much less serious in childhood, than at or after puberty; — 4th, and most especially on the presumed extent of disor- ganisation, and caries; the occurrence of local paralysis, but particularly of the cerebral symp- toms alluded to (§ 22.), being very unfavourable. All chronic discharges from the ear, however slight they may seem, should be viewed in a serious light, not merely as they generally lead to deaf- ness, but as they are also liable to be followed by fatal cerebral disorganization. 25. iii. Causes.—A. The predisposing causes of otitis and otorrhaa are, delicacy and suscep- tibility of frame; the scrofulous diathesis; the pe- riods of dentition and childhood; the syphilitic poison; and disorders ofthe prima via and diges- tive organs generally.—B. The exdting causes are chiefly a current of cold air; exposure to cold air after the removal ofthe hair; the introduction of foreign bodies into the meatus; accumulations of wax in this part, or the use of irritating injections; herpetic eruptions on other parts of the body, or porriginous eruptions on the scalp, and the sup- pression of either; inflammatory affections of the throat, tonsils,and fauces; and determinations of blood to the head. Either the acute, sub-acute, or chronic states of the disease may supervene in the course, or after the subsidence, of any of the exanthemata, or even of continued fever, but more especially scarlet fever, small-pox, aud erysipelas. Difficult dentition, the irruption of the wisdom teeth, caries ofthe teeth, and injuries of the head, are more rarely exciting causes. M. Itard thinks that falls upon the head may occasion otitis with- out producing disease of the brain. It may follow even slight attacks of catarrh in children; and in some instances its cause is by no means evident. 26. III. Treatment.—The means of cure dif- fer according to the acuteness, the seat, the stage, and the particular characteristics of the inflamma- tion; and the results to which it has given rise. 27. i. Of the Acute.—A. Acute external Otitis, whilst the pain is moderate, and febrile symptoms are absent, requires chiefly the removal of all sources of irritation, the injection of tepid and simply emollient fluids, and the application of poultices. When the pain is severe, and febrile commotion is present, general or local bleeding— the former in patients who are more than a few years of age, either from the arm, or from the jugu- lar vein—should be prescribed; and, if there be not much fulness of blood in the head present, an eme- tic, as recommended by Dr.KENNEDY, exhibited. After its operation, a full dose of calomel with James's powder ought to be given, and followed in a few hours by an active cathartic draught. If the symptoms be not greatly relieved by these, a number of leeches should be placed behind the ear, or cupping performed on the nape of the neck, a blister being subsequently applied in this situation. n of — Treatment. 74] In this stage and state of the disease, the intro- duction of any substance into the meatus beyond simple emollient injections occasionally, is more injurious than beneficial. Some writers recom- mend the use of narcotics; but unless the harm- less decoction of poppy heads, they are as well abstained from. M. Itard advises two or three grains of camphor, rolled ih cotton, to be placed in the meatus, if there be no discharge; but this appears more suitable in sub-acute and slight cases, than in those that are very acute. Dr. Lehman directs the tincture of digitalis to be dropped into the ear, or cotton impregnated with it to be intro- duced. When a discharge takes place, the sim- plest tepid injections only should be employed; and, during the course of treatment, a free action on the bowels kept up. The blister on the nape of the neck should also be preserved open; and leeches again applied behind the ear. When the pain has subsided, a mucous discharge only re- maining, M. Andral prescribes slightly astrin- gent injections, and particularly those consisting of the waters of Barreges. I believe that the less they are employed the better; attention to the functions of the stomach and bowels, and change of air, with such means as may promote the gen- eral health, being the safest and best means. 28. B. Acute internal Otitis, demands the prompt and decided use of the above remedies. After general depletion, the repeated application of leeches behind the ear, at short intervals, is often requisite, with external derivation, &c. If the exhibition of an emetic after these fails of re- moving the acute symptoms, antimonials should be given, so as to produce nausea and keep dovvri vascular action; the bowels being also freely acted on. For this purpose, calomel with small doses oi tartar emetic or James's powder should be prescribed every three or four hours. These means will generally be followed by resolution of the inflammation, and subsidence ofthe symptoms, if resorted to at an early period. But if the disease pass on to suppuration, the patient will complain of a throbbing pain, with a bursting sensation in the ear, and persistence, or even aggravation of his sufferings. In this case, an additional indi- cation must be fulfilled, viz. the speedy evacu- ation of the matter collected in the cavity ofthe drum, as its retention will materially aggravate the disease, and endanger the bony structure of the ear. Several authors have advised, in such circumstances, the application of fomentations and poultices, to accelerate the ulcerative perfora- tion ofthe tympanum and the external evacuation ofthe matter. These are, however, often ineffi- cient. In order to remove obstruction ofthe Eusta- chian tube usually existing in such cases, gargles with a solution ofthe sub-borate of soda, or of nitre and it, may be employed. Some writers recom- mend the smoke of tobacco to be forced into the tube whilst the mouth and nose are shut. But these means do not often succeed. Instead of wait- ing for the spontaneous evacuation of the pent up matter, which insinuates itself under such circum- stances into the various sinuosities of the ear, M. Itard advises, and has in many instances prac- tised with benefit, perforation of the membrane of the drum. Having performed this operation, it is generally requisite to inject mild tepid fluids in order to procure the full evacuation of the matter, which has often become more or less consistent. 70 742 ECTHYMA. If inflammatory symptoms either continue or re- turn, after the perforation ofthe tympanum, anti- phlogistic measures should be directed; but if the discharge continue, the patient should sleep on the side on which the ear is affected, diluent and emollient injections being occasionally employed, so as to prevent any clogging of the meatus, and accumulation of matter in the middle ear. M. Itard directs, with this view, an injection form- ed of a drachm of caustic potash to the pint of rosewater. Light tonics and mild laxatives, with change of air, ought also to be prescribed, so as to prevent the disease from degenerating into the ulcerative and chronic states. 29. ii. Of Chronic Otitis. — When otorr- hoea becomes established after acute otitis, as above, or follows a slight or imperceptible state of inflammatory irritation, the treatment may be divided into the local, and general,— the latter more especially being directed against the state of constitutional disorder. Local depletion is re- quired only early in those cases which present more of a sub-acute character, or when this, or even acute symptoms supervene from obstruction to the discharge, or any other cause. Blisters behind the ear, stretching to the occiput, or on the nape of the neck, and either kept discharging or repeated, are often very serviceable. M. An- dral notices setons, or cautery of the nucha, or issues in the extremities. M. Itard directs, in addition, the head to be shaved, rubbed assiduous- ly with stimulating substances, and kept constantly covered with a gummed silk cap. He very judi- ciously forbids the use of any other than simply diluent or emollient injections. Even gently as- tringent fluids ought not to be resorted to until the discharge begins to diminish; if its diminution be not attended by any aggravation of the local or constitutional symptoms. In this case, the mildest astringents may be commenced with, and those which are more and more active successively em- ployed. A weak infusion of roses, or of chamo- mile flowers, may be first prescribed, and subse- quently a weak solution of the sulphate of zinc, or of kredsote in distilled water. Oily injections, in cases of otorrhcea, should not be used, as the oil speedily becomes rancid when any part of it re- mains in the ear. Whenever the discharge is suddenly suppressed, means should be taken to restore it. Warm bread and water poultices or fomentations, frequently renewed, may be resort- ed to with this intention. M. Itard directs bread warm from the oven, and deprived of its crust, to be applied every three hours, and an injection of a solution consisting of three grains of corrosive sublimate in eight ounces of water. Care should also be taken to remove any obstruction that may present itself in the meatus. If the suppression be attended by the accession of acute symptoms, leeches must be applied; but the powers of life ought not to be much reduced by these or any other means. Mercury in this state of disease is injurious. If matter form in the vicinity of the mastoid process, an early outlet should be given to it by a free indsion down to the carious bone, and the powers of life supported by gentle tonics, light nutritious diet, and change to a healthy air. When caries is obviously present, and there is no increase of sensibility, or any other symptom of acute inflammatory action, M. Andral advises injections of a strong solution of potash to be fre- quently thrown into the ear. When, however, there is evidence ofthe caries having induced dis- ease within the head, the simply diluent injections should only be used, in order to prevent any inter- ruption to the discharge. 30. By the constant use of simple diluent or emollient injections — of warm water, or milk and water merely — and careful attention to the general health, the disease may be kept stationa- ry, from youth to old age, although it may not be cured. In scrofulous and lymphatic subjects, the bitter tonics; the infusion or decoction of bark; the kredsote internally; the preparations oi iodine in gentle doses; the ioduret of iron, or the am- moniated or tartarized iron; and mild purgatives, once or twice a week; will be extremely service- able, if there be no acute symptoms, or febrile action. I have also seen much benefit accrue from sulphur given daily in sufficient quantity to keep the bowels freely open. If the disease seems con- nected with a syphilitic taint, or has come on after syphilitic sore-throat, or an inefficient course of mercury, the oxymuriate of mercury should be given in gentle tonics, or with a course of sarsapa- rilla. Where there is fever, with a loaded tongue, or pain in the head and ear; in addition to those appropriate local means above stated, (§ 28.), a course of mild and cooling purgatives or aperients, external derivatives, diaphoretics, and a mild fa- rinaceous diet, should be employed. Change of air, and such mineral waters as may suit the pe- culiarities of the case — the chalybeate, aerated, and sulphureous, in cases devoid of fever and other acute symptoms; the aperient and refrige- rant in those thus accompanied—will be very powerful.adjuvants. (See Art. Hearing.) Biblioo. and Refer.—Oribasius, De Loc. Affect. I. iv. —Aitius, 1. iv. c. 74.—Actuarius, 1. vi. c. 3.—Alexander Trail.. 1. i. c. 21.—Paulus JEgineta, 1. iii. c. 23.—Brotbeck, De Inflam. Aurium. Tub. 1667.—Forestus, I. vii. obs. 19.. etl.'xii. obs. 7.—Schenck, 1. i. obs. 351.—Duverney, Traite de l'Organc de l'Ouie. Par. 1683.—Bonet. Sepulchre!. I. i. sect. 19. obs. 1.—Schulze. De Aur. Manentihus el Ulceratis. Hal. 1743.—A. Bergen, De Morb. Auris Internae. Fr. 1754. —Morgagni, De Caus. et Sed. Morb. epist. xiv. 3. 5. 7.11. 13. kc.—A. Dun an, Med. Comment, vol. ii. p. 286.— Weickard, Verm. Schriften. b. i. p. 78.—Heberden, Com- ment, in Morb. Hist, et Curat, cap. 12.—Frize, Diss, sistens p xcipuas Aur. Morbos. Fr. 1789.—Bourienne, in Journ. de Med. t. xii p. 342.—J. P. Frank, De (ul. Horn. Moib. 1. ii. p. 90.; et Interp. Clin. vol. i. p. 141.—Thiele, in Rust's Magazin f. d. Ges. Heilk. b. ii. par. i. p. 164.—Sturke, in Ibid. h. ii. par ii. p. 311. ; et Ibid. b. iv. par. i. p. 197.— J. C. Saunders, Tb ■ Anat. and His. of the Hum. Ear. Lond. 1806.—Alurd, Sur le Catarrhe de I'Ore He, 8vo. Par. 1808. —Earle. in Trans, of Med.-Chir. Soc. vol. x. p. 410.—Swan, in Ibid. vol. xi. p. 330.—Duncan, in Edin. Med. and Surg. Journ. vol. xvii. p. 331.—Swan, in Ibid. vol. xvii. p. 4.il.— Itard. Traite des Malad. de 1'Oreille, et de 1'Audition, t. i. p. 160. et seq.—Andral, in Diet, de Med. t. xvi. p. 6.1.— Lallemand, Recherches Anal. Pathol, sur l'Enceph. et ses Dependances. Let. 6. Paris, 1830, Hvo.—J. H. Curtis, Treat. on the Phys. and Pathol, ofthe Ear, 5th ed. Lond. 1831.— Buchannan, Op. cit. passim. ECLAMPSIA. See Convulsions (§24.27.). LTSTASY. See Cataleptic Ecstasy, &c. ECTHYMA. Syv.—*E*6vuvt (from t'x<.V,.., I break forth), Willan. TIqu i i Poc, terebinthus of the Greeks, according to Hoffmann; or 7->»- /Jn-oV-, Cicer., as it is read by others with more reason,Turner; also F.;m\y.ri; (from t:n and ii':), owing to its appearing or being aggravat- ed at night, according to Celsus, Galen, Paulus, and Aetius. 2'eTmtn(Aus,YV iseman, Turner, &c. Phlysis Ecthyma, Young. Ecpyesis Ecthyma, Good. Psydracia, J. P. Frank, Chiarurgi, and J. Frank. Phlyzadon, Paget. Dartre Crus- ECTHYMA — Acute — Chronic — Pathology. 743 tace'e, Furoncle Atonique, Fr. Erbsenblattem, Eiternde Flechte, Germ. Papulous Scall. Classif. — 5. Order, Pustular Eruptions (Willan). 6. Class, Dis. of Excernent Functions; 3. Order, Affecting the Skin (Good). III. Class, I. Order (Au- thor, in Preface). 1. Defin.—An eruption of large, round, and distinct pustules, seated on a hard, elevated, red base, and terminating in a thick, hard, and dark- coloured scab, leaving a livid spot or superficial cicatrix; not contagious. 2. I. Description.—These pustules are al- ways discrete, scattered sparingly, and appear suc- cessively in different parts of the body; and rarely terminate in ulceration or tuberculous induration. They may appear in any part of the body; but they are most frequently observed on the limbs, abdomen, shoulders, breast, and neck — rarely in the face or scalp. They present modified states, according to the causes, the age of the patient, and the severity of the eruption. These Willan has arranged into, Ecthyma Vulgare, E. Infantilis, E. luridum, and E. Cachecticum. To these may be added the Ecthyma Sijphiliticum (Frank, Biett, Cazenave, Schedel, Todd, &c), the syphilitic affection sometimes assuming the ecthymatous form. M. Rayer has adopted a simpler and more correct division, viz. into the Acute and Chronic, which I shall here follow. 3. i. Acute Ecthyma; E.Vulgare, Willan. —In its simpler and rarer form, ecthyma appears in some one part of the body, most frequently ou the neck and shoulders, in the form of circum- scribed reddish elevations, firm to the touch, and distant from each other. Pus soon is formed at the summit of these elevations; and the pustules are completely developed in three or four days; their bases being much inflamed, elevated, large, hard, and circular, — of a bright red in young persons, and of a livid red in the aged. Their suppurating summits generally break in one or two days after their formation; the purulent mat- ter giving rise to a brownish, or greenish, and very adherent scab. After one or two weeks, the scabs are detached, and leave a livid red mark, or occasionally very superficial cicatrices, of the size of those of small pox, but much-less deep. The eruption of the pustules is attended with stinging pains in them; sometimes with tu- mefaction of the adjoining lymphatic glands, and is often preceded or accompanied by chronic inflammation of the digestive mucous surface, which may continue after the healing of the pustules. This variety is seldom attended by fever. 4. ii. Chronic Ecthyma is much more fre- quent than the preceding, and always consists of several successive eruptions on the limbs, neck, breast, &c, at periods more or less distant. The pustules present the same characters, and follow individually, and independently of each other, the same course as above described; some making their appearance whilst others are suppurating, or even healing. During several months, divers eruptions are thus formed. Besides the succes- sive eruptions, the pustules themselves may be more chronic, their bases assuming large dimen- sions, approaching those of boils, and being tense and prominent. In these cases, the subjacent cellular tissue is inflamed, their areola? becoming hard and violet-coloured—Ecthyma luridum oi Willan. Their summits break in eight or ten days, and discharge a little sanious or bloody mat- ter, sometimes ulcerate slightly, and are covered by hard and black crusts or scabs, which adhere firmly, and are surrounded by livid red areola?, which sometimes remain after the crusts have fallen off; this taking place in the course of a few weeks; leaving dark red spots, or livid cicatrices, after them. If the scabs are torn away before the period at which they usually fall off, small indolent ulcers, with callous borders, giving issue to a sanious fluid, are often produced. When the pustules remain long stationary without ulcerating, they are occasionally followed by violet-coloured tubercles, which may ultimately suppurate or ul- cerate, and more deeply mark the skin. A symp- tomatic form of this eruption, which is often tedious and severe, sometimes attends the cachexia con- sequent on measles and other'eruptive fevers; but it differs in nothing from the disease now described, excepting in the number of the pustules, and the marked constitutional disorder. 5. The successive eruptions characterising this variety are observed chiefly in feeble and ill fed children—(Ecthyma Infantile of Willan).— When the number of pustules is small, and the successive eruptions are distant from each other, there is generally little or no fever. But when the pustules are numerous, their bases very large and much inflamed, or if they ulcerate, there is usually present a co-ordinate degree of fever— Ecthymu Febrile, E. Cachecticum. —The febrile symptoms sometimes precede, and at other times accompany, the severer forms ofthe eruption, par- ticularly in unhealthy and aged persons; and are also attended by gastric and intestinal disorder,— by anorexia, pain at the epigastrium', irregularity or constipation of the bowels, a morbid appear- ance of the tongue, gums, and fauces, and of the evacuations, headach, pains in the limbs, lassitude, and by great depression of spirits, — with heat, stinging, tingling, or itching in the pustules. In such cases, as well as in other chronic states, this eruption is often complicated with swellings of the lymphatic glands, with inflammation of the conjunctiva, or of the fauces, or of the pharynx; with oedema of the lower extremities; and with other cutaneous eruptions, especially with rupia and furunculus. It is also frequently associated with, or rather symptomatic of, chronic inflam- mation of the digestive or respiratory mucous sur- faces, and biliary derangement. The duration of chronic ecthyma is always subordinate to the suc- cessive eruptions of pustules, to the habit and constitution of the patient, and the treatment em- ployed. It is usually from two to four months; but it may be longer or shorter. 6. When syphilitic disease gives rise to erup- tions with the characters of ecthyma—E. Syphi- liticum; PsydradaVenerea, J. Frank ; Syphilide pustuleuse Phlyzacie, Biett, Rayer, &c.; Pus- tular Venereal Disease, Carmichael—the pustules are always surrounded by broad, dark, copper-coloured areolae, and are very large, indo- lent, and inclined to ulcerate. The ulcerations, when the scabs are detached, are deep, greyish or pale, unhealthy, with abrupt and violet-col- oured edges; but they seldom extend, the scabs gradually reforming over them, and being suc- cessively detached, until they heal under appro- 744 ECTHYMA — Diagnosis — Causes—Treatment. priate treatment, leaving permanent, round, cop- per-coloured cicatrices. This form of the syphi- litic eruption is most common in children born with the infection, the pustules being numerous, fiat, and sometimes oval, followed by ulcerations; the skin foul and dingy; and the body emaciated (Cazenave and Schedei..) 7. II. Diagnosis.—The pustules of ecthyma are easily recognised, by their form, their size, their inflamed base, and mode of developement; and distinguished from those of acne, of impetigo, mentagra, or porrigo. — a. However, when the pustules of mentagra or of acne present, as they occasionally do, hardened red bases, they may be mistaken for the phlyzacious pustules of ecthyma, if the induration, rather than the inflammation, were attended to; but the specific characters of these eruptions are sufficiently distinct. — b. The umbilicated pustules of small-pox, the multilocu- lar pustules of vaccinia, independently of their contagious properties, cannot be mistaken for those of ecthyma. — c. The inflammation in fu- runculus begins in the sub-cutaneous cellular tissue, and extends outwards ; in ecthyma, it commences in the' skin, and proceeds inwards; the former being either single, or much less nu- merous, and much larger. — d. Rupia sometimes is coetaneous with ecthyma, in its chronic form -- E. luridum and Cachecticum; the latter seem- ing to be converted into, or appearing to be an earlier stage or less severe grade of, the former, more especially in cachectic children, as correctly alluded to by Mr. Dendy, whose experience in cutaneous diseases, as my colleague at the In- firmary for Children, has been most extensive. But the early stages of both will sufficiently dis- tinguish them from each other, independently of the prominent and thick crusts, with the deep ulcerations, characterising rupia. — e. The itch presents only a iew analogies with ecthyma, when it is complicated with, or when its ve- sicles are accidentally transformed into, pustules. In ecthyma, the pustules are rarely numerous; they appear successively, the course of each be- ing independent of the rest. But in itch, the accidental pustules form on the most inflamed points; are always intermixed with the small vesicles, by which it is characterised; are more agglomerated than in ecthyma; are seated chiefly on the hands, between the fingers, especially be- tween the thumb and forefinger; and are attended by itching; whilst the pustules of ecthyma produce a stinging pain; the itch, moreover, being vesicular and contagious. 8. III. Causes. — Ecthyma attacks all ages and constitutions; but it is most common in adults of a sanguineous temperament and bad habit of body; or in persons who have prematurely ex- hausted the powers of the digestive organs, and vital energies of the system generally. It occurs at all seasons; but is most frequent in spring and summer. Unwholesome and insufficient nourish- ment; cold and moist habitations; want of per- sonal cleanliness, especially among those who wear foul woollen next the skin, or who are scantily clothed ; and the irritation of various mineral and pulverulent substances; are its most common causes. Hence it is prevalent chiefly among the poor, and mechanics (Psydracia Ar- tificum, J. Frank), whose occupations subject thgm to these contingencies. Great fatigue, pro- longed watching, anxiety or distress of mind, in- attention to the states ofthe stomach and bowels, and whatever lowers the digestive aud assimilat- ing powers, and energies of life, inducing general cachexia, will occasion this form of eruption. The chronic states oi the eruption are most fre- quent in the indigent; in persons living on stale, smoked or salted provisions; or whose constitu- tions are broken down by imprudence, misfor- tune, drunkenness, age, and irregularities; or in ill-nourished and debilitated children, living in low, damp, dark, and close cellars, &c. Ecthyma often also follows small-pox, the itch, scarlatina, measles, the bites of leeches, and the application of irritating plasters or unguents. The tartarized antimonial ointment produces pustules of this kind. It may be symptomatic of pregnancy, and of several diseases of internal organs, especially of the prima via. Indeed, it may be in most instances considered as one of those infinitely diversified expressions of morbid action on the external surface, attendant upon prolonged dis- order of the digestive and assimilative organs. Hence it cannot be a matter of surprise to find it sometimes associated with other chronic diseases of the skin. From the foregoing it follows that this eruption is dependent upon the general state of the system, to which our treatment should be chiefly directed in all its forms. This state is evidently one of debility, accompanied frequently with erethism, or morbid irritability, and essen- tially with altered sensibility and deficient tone of the vascular ramifications in the cuticular and sub-cuticular tissues. 9. IV. Treatment.—A. In the Acute form, when the pustules are few, little more is requisite than a mild diet, tepid baths, cooling aperients, and two or three grains of hydrarg. cum creta with dried sub-carbonate of soda or potash, at bed-time. Whey is the best beverage; and, if the patient be robust and the pustules numerous, a small bleeding, or leeches to the anus (Caze- nave, &c), may be resorted to. If the stools be morbid, the soda tartarizata, or the soluble tartar, should be given with infusion of senna, and after- wards the compound infusion of roses may be taken with small doses of either of the sulphates; or these latter may be taken in tonic infusions, with the addition of a little dilute sulphuric acid. 10. B. The Chronic states generally require gentle tonics, with alteratives, and light nourish- ing diet. — a. When they occur in infants, the nurse should either be changed, or the treatment directed chiefly to her. Where this cannot be done, asses' or goats' milk should be substituted or given in addition ; and the regimen strictly regulated. Change of air, warm salt water bath- ing or sponging, and gentle alteratives, will also greatly assist the cure. Hydrarg. cum creta, and the sub-carbonate of soda or potassa at night; the liquor potassa? in tonic infusions twice a day, and an occasional purgative in the morning; small doses of the chloruret of potash, or of the hydri- odate of potash; warm salt-water bathing, and afterwards the ferruin tartarizatum; have been the most efficacious remedies, in these states, in my practice among children. The chlorate of potassa, and the other chlorates, were first em- ployed by me, in this disease, many years ago, at the Infirmary for Children. 11. b. In grown up or aged persons, we should ECZEMA —Pathology. 745 always suspect disorder of the digestive and assi- milating functions; and, if there be little or no fever, have recourse to deobstruent alteratives, as Plumper's pill, with soap, or taraxacum, at night; a stomachic purgative every second or third morning, and the decoction of sarsaparilla; or mild tonic infusions with soda or potash, in the course of the day. If we suspect conjestion of the liver, or find tenderness of the stomach on pressure, small local depletions should be em- ployed, and repeated according to circumstances, whilst the above depurating and mildly tonic re- medies are continued. Mercurials should not be given in large doses. Plu.mmer's pill, blue pill, or hydrarg. cum creta, with taraxacum, inspissated ox-gall, guaiacum, and sarsaparilla, are the most beneficial. The occasional exhibition of purg- atives, or the association of them with tonics, is also necessary, especially if the stools be morbid, and the abdominal viscera require to be excited. In such cases, a prolonged course of tonic or sto- machic purgatives is often necessary. 12. c. When the cachectic state is complicated with some degree of febrile action (§ 5.), the mild mercurials now particularised should be con- joined with James's or Dover's powder; and sa- line diaphoretics exhibited at short intervals; the morbid secretions and faacal accumulations being evacuated from time to time, by cooling purg- atives. If there be tenderness at the epigastrium, a few leeches applied there will materially assist these remedies. After these, the infusion or de- coction of cinchona, with liquor ammonia? acetatis, ou with the pyroligneous acid, or with nitrate of potash and sub-carbonate of soda; a course of tonic infusions, with alkalies and the extract of taraxacum ; tepid or warm bathing ; the mi- neral acids with anodynes; and the other means particularised in the last paragraph; may severally be exhibited. Having removed fever, and eva- cuated morbid matters, more active tonics, as the quinine in the compound infusion of roses, with tinctura opii; the decoctum cinchona? with the mineral acids, or with camphor <-uid ammonia; chalybeate preparations, sarsaparilla and guaia- cum, the balsams and terebinthinates with mag- nesia, common tar made into pills with this ab- sorbent, the bark ofthe madar root, &c., may be prescribed. 13. d. The syphilitic form of ecthyma should be treated in the manner described in the article Acne (§30.). Mr. Carmichael does not con- sider this eruption as being truly syphilitic, and therefore confides chiefly in sarsaparilla with an- timonials and guaiacum. In a case of this form of syphilitic eruption, lately attended by my friend Mr. C. Hutchison and myself, oxymuriate of mercury, given in sarsaparilla, was required for its cure, milder means not having succeeded. Dr. A..T. Thomson advises this preparation in minute doses to be given in the decoction of elm- bark, or in the emulsion of bitter almonds. In the cases of infants, some French physicians re- commend the milk of a goat on which mercurial ointment has been rubbed. When the child is at the breast, the nurse should enter upon a gentle course of the oxymuriate in the decoction of sar- saparilla, or in almond emulsion. 14. e. External means are sometimes required to remove the irritation attending the eruption, aud to heal such as ulcerate. With these inten- 63 tions, tepid alkaline baths; fbmentetiens with a decoction of poppy-heads; a weak solution ofthe chlorurets of lime or of soda, especially when there is ulceration; or solutions of chlorine, or of sulphate of zinc with hydrocyanic acid, or of the nitro-muriatic acids, or of nitrate of silver, &c; may severally be employed. Dr. A. T. Thom- son recommends the following: — No. 209. R Plumbi Acetatis ^ss.; Acidi Hydrocyanici 3 iij. ; Unguenti Cetacei 5»j- M. Fiat Unguentum par- tibus cutis nudis applicandum. 15./. The diet in the acute form ought to be bland and farinaceous, whey and emollient fluids, or water with a little vinegar, being the chief beverages.— In the chronic slates, light and nour- ishing food, if there be no fever, or after fever is removed, is always requisite. In the more cach- ectic cases, a small quantity of wine should also be allowed. The patient will always derive ben- efit from the internal use of tar-water, which may be taken as the common drink in these cases. This medicine, which was formerly so inordinate- ly praised, and, owing to this circumstance, now so undeservedly neglected, is most serviceable in this and many other chronic affections of the skin. In addition to these, frequent tepid and warm baths, and subsequently salt-water bathing, exer- cise in the open air, change of air, mental recrea- tion, warm and suitable clothing ; regularity in eating, drinking, and sleeping; early rising, and a regular state of the bowels, are important adju- vants. Bibhoo. AND REFER.—Celsus, lib. v. cap. 28.—Paulus AVgineta, 1. iv. cap. 9.—Oribasius, Synops. I. vii. c. 37.— Avicenna, I. iv. fen. iii. t. i. c. i., et fen. vii. t. iii. c. i.— Hoffmann, Institut. Med. 1. iii. cap. 154.— D.Turner, Treit. of Dis. incident to the Skin, 5th edit. Lond. 1736. p. 118.— Lorry, Tract, de Morb. Cu aneis, 4tn. 1777, p. 250.—J. P. Frank, De Cur. Horn. Morb. vol. iv. p. 180.— J. Frank, Praxeos Med. Univ. Piaecepta, partis prima; vo1. secund. p. 432.—Willan, On Ecthyma, 4to —R. Carmichael, Essay on Ven. Dis. confoundeel with Syphilis, part i. Dub. 1814 ; and on Venereal Diseases, 1825.—W. C. Dendy, On the Cutaneous Dis. incidental to Childhood, 8vo. Lond. 1827, p. 134.—T. Bateman, Pract. Synop. of Cutaneous Dis. 7lh ed. by Thomson, p. 257.—Hewson, North American Med. and Surg. Journ. 1826.—Plumbe, Diseases of the Skin, 2d edit. p. 440.—C. E. Asselin, Essai sur l'Ecthvma. Paris, 1827.—P. Rayer, Traite Theorique et Pratique des Mala- dies de la Peau, vol. i. p. 430.—Cazenave et Schedei. Abrege Prat, des Mai. de la Peau, 8vo. Par. 1828, p. 187.—J. Pa- get, On Classification as applied to Dis. ofthe Skin, &.c. 8vo. Edin. 1833. ECZEMA. Syn. — Eczemata (from txttn, I effervesce). Ecsesmata, Blancard. Hidroa, Sauvages, Vogel. Ecphlysis Eczema, Good. Cytisma Eczema, Young. Hydrargyria, Al- ley. Mercurial Lepra, Mercurial Disease, Moriarty and Mathias. Hitzblatterchen, Germ. Dartre Squameuse humide, Dartre Vive, Hy- drargyrie, Fr. Heat Eruption. Classif. — 6. Order, Vesicular Eruptions (Willan). 1. Group, Eczemata (Alibert). 6. Class, 3. Order (Good). III. Class, I. Order (Author). 1. Defin. — An eruption of minute vesicles, uncontagious, crowded together, and terminating in the absorption of the fluid they contain, or in superficial excoriations, with more or less serous- exudation, concreting into thin flakes or crusts. 2. I. Description.— This eruption may be confined to a single part of the body, or it may attack several parts, or even the whole surface. It most frequently appears in the axilla^ the in- sides of the thighs, the groins, hams, &c. When it is more general, it often extends over the backs 746 ECZEMA — Acute — Chronic — Pathology. of the hands, the face, scalp, neck, and fore-arms. It often occurs on the scrotum and verge of the anus, on and around the nipples, and in the vulva. Eczema presents various modifications, distin- guished by Dr. Willan into the E. solare, E. impetiginous, and E. rubrum. MM. Biett and Rayer have, I think more correctly, divided it into the Acute andCHRONic—a division which i shall partially adopt. 3. i. Acute Eczema.—The eruption of the vesicles of this form is preceded and accompanied by a sensation of heat and tingling of the affected parts, aggravated to smarting on being exposed to heat —A. In its most simple form —Eczema sim- plex— the skin still preserves its natural colour; and the vesicles are very small, very crowded, and hardly inflamed at their bases. The serum which they contain is at first limpid, afterwards opaque, milky, or turbid; and is ultimately absorbed, or dried on the summit of the vesicles after their rupture. In this latter case, which is not fre- quent, small epidermic flakes, and minute crusts of the size of a pin's head, are observed. These are soon detached; and often, in the space of one or two weeks, no traces of the eruption remain. Such is the usual course of the slightest state of eczema, as when it follows the action of the sun's rays, or of topical irritants, &c. It occurs most commonly in young persons, particularly females; is attended by no fever; but is sometimes compli- cated with lichen, and with psora. 4. B. When the inflammation is more acute, the skin becomes red and shining, as in erythema or erysipelas, at the same time that it is covered by minute vesicles — Eczema rubrum, Willan. — It commonly appears about the parts provided with hair, as the organs of generation, the margin of the anus, bends of the arms, wrists, and neck; and is more frequent and much more severe than the foregoing. The vesicles are small, crowded, or confluent, transparent, slightly shining, sur- rounded by red areolae, especially in young, ple- thoric, and strong persons. They remain limpid until they burst, — about the fifth or sixth day, — frequently giving issue to a milky or reddish se- rum; and are replaced by small, yellowish lamellae or flakes. In the slighter grades of this variety, the fluid is often absorbed, and the cuticle forming the vesicle exfoliates; but in the severer grades, the contents of the vesicles, when they burst, irri- tate the already inflamed surface, occasioning superficial excoriations, with a more or less abund- ant exudation of serum,_ which ultimately lessens, becomes thicker, and at last concretes, form- ing, with the detached cuticle, thin lamella? or crusts. 5. C The vesicles of eczema may be associ- ated with small psydracious pustules — E. impe- tiginodes of Willan.—The inflammation is then carried to its highest degree, is preceded by a sensation of tension in the affected part, of burning heat, or attended by smarting, and intense itching, and considerable tumefaction. The vesi- cles are confluent or agglomerated,—at first trans- parent, assuming, in three or four days, an opaline hue, and passing into a sero-puriform state, being moreover interspersed with psydracious pustules. They all discharge a fluid having a faint unpleas- ant odour, and irritating the parts with which it comes in contact. 6. D.— a. In the simple acute Eczema there is usually at first not much disorder beyond that of the affected part. But in the E. rubrum and E. impetiginodes, there is generally febrile action, the intensity of which is proportionate to the local irri- tation. Not infrequently the eruption is preceded by gastro-intestinal irritation or disorder, the symp- toms of which are often very manifest both before and at the time of the eruption. The lymphatic glands in the vicinity of the eruption are often swelled and painful. This form of the disease is almost always consequent upon appreciable ex- ternal causes (§ 15.).—b. Its duration is com- monly from two to three weeks. But the simplest variety maybe a week less, and the severest form a week longer; the affected parts not losing their red colour for a considerable time longer. 7. ii. Chronic Eczema—may present the three grades of acute eczema particularised above, — the E. simplex, E. rubrum, and E. impetigi- nodes, whatever may be the causes which produce them. — a. When the inflammation is aggravated after the breaking of the vesicles, it may be ex- tended to the deeper layers of the skin, and even to the sub-cutaneous tissue. The skin becomes very painful, is excoriated, its cuticle fissured; and, when it is very much irritated, resembles a blistered surface in a state of suppuration — the Dartre Squameuse humide oi Alibert — and constantly exudes an ichorous fluid, which resem- bles drops of dew, and is often so abundant as to penetrate all the linen wrapped around the part. It is chiefly when the eruption has reached this height, that it is attended with the most insup- portable itchings. The skin is then so acutely inflamed as to be as red as carmine in some parts. Repose at night is impossible, unless at intervals, when the smarting, stinging, or itching subsides; but this symptom suddenly returns without any obvious cause; when scratching ofthe part, some- times until blood is poured forth with the exuded serum, cannot be longer forborne. 8. b. After a time, varying from a few weeks to many months, the inflammation subsides. The exuded serum becomes less abundant, thickens, and forms into thin, soft, yellowish brown, and semitransparent crusts, but little adherent, often very large, leaving beneath them, when detached, an inflamed and a slightly moistened surface. These crusts form more slowly, become drier, &C.; and then, without any obvious cause, the in- flammation and the serous exudation resume their former intensity; or, when the healing process has proceeded further, the surface again becomes red, vesicles reform, break, and the affection fol- lows the same course. Lastly, in some cases, no further exudation takes place: the crusts become drier, less yellow, and more adherent; often thickened, fissured, or chopped, and easily de- tached, leaving the surface but little inflamed. Sometimes, however, in the more extensively dif- fused state of the disease, the skin remains, even for several months, of a bright red; is covered in parts by dry and thin scales or flakes; and is in some places cracked, but without any perceptible exhalation. In this case, the eczema resembles certain scaly affections, especially psoriasis,—the more, as these scales arise, not as heretofore, from an exhalation and concretion of lymph, but are, as in the scaly eruptions, the lamella? formed of diseased epidermis. In some cases, especially on the limbs, there remain but two or three small ECZEMA — Specific —Diagnosis. 747 places, the skin of which seems thin, stretched, shining, and smooth ; its surface being covered by whitish and extremely thin scales, as if formed of epidermis, but without the least appearance of vesicles ; the diagnosis being difficult, if the previous history, or the appearance of vesicles about the circumference of the excoriated part, did not render the nature of the eruption evident. 9. c. Chronic Eczema, although generally at first very limited, may extend over a wide surface, so as even to cover a whole limb, or the greater part of the body.— a. When it attacks the face, the redness and swelling, with oedema ofthe eye- lids, are considerable ; and sometimes associated with inflammation of the conjunctiva.— p. It occasionally is seen in the ears, especially when it affects the scalp, and is then often mistaken for a variety of porrigo, and it is sometimes associated with otorrhcea.— •/. When it attacks the scalp, it exudes a viscous fluid having a faint and nau- seous odour. As it subsequently diminishes, it concretes into lamellated or furfuraceous crusts, which are easily detached. At last the secretion entirely subsides, the skin passing into a scaly state, and becoming the seat of an abundant and constant desquamation, the removal of the scales leaving the skin red, shining, and irritated. Eczema of the scalp may continue many months. It is generally attended by swelling of the posterior cervical lymphatic glands; and it occasions change or loss of the hair.— 8. When it is seated in the upper parts of the thighs, it often spreads to the anus, the scrotum, and to the vulva, occasioning, as indeed in its other severe forms, the most in- supportable stinging and itching. If it extend to the penis, the prepuce is often fissured; painful itching, irritation, and erections, being caused by it.— t. Eczema may be complicated with lichen, with scabies, with impetigo, and with ecthyma. 10. iii. Specific Eczema — Mercurial Ecze- ma, Mercurial Disease, Schreiber, Moriar- ty; Hydrargyria, Alley ; Exanthema Mercuri- ale, J. Frank — is, in its slighter grades, and as respects the characters of the eruption, in every respect the same as the acute and chronic Eczema rubrum. But the constitutional symptoms are much more severe, and the disturbance of the nervous system much greater, in the former than the latter ; whilst the eruption is much more ge- nerally and more • frequently diffused over the surface. Both in these lesser grades, and in the severer states about to be described, it is ushered in by much constitutional disturbance — espe- cially furred tongue, accelerated circulation, and increased sensibility and irritability. 11. The more severe states of this affection were first described by Benjamin Bell, Spens, Moriarty,Pearson,M'Mullin,Chisholm, and Alley. Besides being preceded by a well- marked febrile paroxysm, these grades are often accompanied by difficult respiration, tightness across the chest, and dry cough, the skin being very hot, and the seat of a smarting and stinging sensation. When the disease is consequent on mercurial inunction — for it may also follow the internal use of mercurials—a diffused redness, with numerous crowded vesicles, supervenes in one or two days, generally on the thighs, scrotum, fore-arms, &c. In some cases, the eruption pro- ceeds no further than the parts where frictions have been applied, and, after one or two weeks, subsides. But in the severer grades, the skin is extensively studded with vesicles, which soon break, discharging an irritating and offensive fluid, which concretes into large incrustations of a dark colour. At the same time the fauces, and frequently the conjunctiva, are greatly inflamed; and the face itself covered with incrustations, fis- sured in different directions. The eruption ex- tends over a large space, and spreads in succes- sion over most of the body; the excoriated sur- face being the seat of constant irritation, which is increased by the pressure of the body, and by the substances which imbibe the exuded fluid. The incrustations crack, and expose the raw sur- face in several places, upon change of posture. If the disease increase in severity, or be still more intense from the commencement, the attendant fever assumes a more adynamic form; diarrlicea is readily induced; the pain in the chest, and diffi- culty of breathing, increase, and are attended by anxiety at the pra?cordia; a dirty, bloody expec- toration, indicating an analogous affection of the respiratory mucous surface, is observed; and ul- timately, if relief be not obtained, the tongue and fauces become dry and dark, and the pulse fre- quent, small, feeble, and irregular. Sometimes sphacelation of the skin, with delirium or con- vulsions, takes place, and death ensues.— Such are the intense states of this disease, according to the physicians now referred to; but it more fre- quently assumes the milder grade described by Dr. Bateman ; and which is characterised chiefly by a less severe and less extensive eruption and excoriation ; by less remarkable constitutional dis- turbance, and by the entire absence, or the slight nature, ofthe pectoral symptoms. 12. The duration of this particular variety is very uncertain. When a limited part is affected, it may terminate in ten or twelve days; but when it is more universal and more severe, recovery seldom takes place in less than as many weeks, or even longer. The whole epidermis is destroyed by the more intense grades of the inflammation ; and when the discharge ceases, it lies loose, and, with the concreted matter, assumes a pale brown colour, changing to black, before it falls off in large flakes. The red cuticle afterwards formed is liable, as in some other diseases, to desquamate again and again, even for a third or fourth time, but in smaller branny scales, of a light colour, a roughness long remaining like slight psoriasis. _ After the intenser forms, the nails and hair fall off; the former, when renewed, being thickened, furrowed, and incurvated. 13. II. Diagnosis.— a. Eczema simplex may be mistaken for scabies, especially when affecting the wrist, and the sides ofthe fingers, or attended by much itching. But the vesicles of the former are flattened and agglomerated; those ofthe latter acuminated and isolated. The irritation or pru- ritus of eczema is rather a smarting or stinging ; whilst that of scabies is rather agreeable than painful. Moreover, the latter is essentially con- tagious, the former is non-contagious.— b. Eczema rubrum may be mistaken for miliaria; but the vesicles ofthe latter are never confluent, as in the former ; and are symptomatic of much constitu- tional disturbance, of which the eruption is a less important symptom than in eczema.— c. E. im- petiginodes differs from impetigo in always occu- pying a large space, the latter being much more 748 ECZEMA — Prognosis—Causes—Treatment. confined. The pustules of impetigo have a larger base, and contain a thicker fluid, than this variety of eczema, which is always vesicular at its com- mencement, its secretion never consisting of true pus. Impetigo also gives rise to thicker, rougher, and more unequal crusts than it ; and is never surrounded by the vesicles of eczema rubrum, as the E. impetiginodes always is.— d. Eczema, in its chronic state, may be confounded with lichen agrius; but the crusts formed by the latter are not so large, nor so thin, as the scales of the former; and when they fall off, they leave not a red, smooth, and shining surface ; but a certain rough- ness, owing to the small prominent papula?, which are generally evident to the eye, and always to the touch. Also, when lichen becomes dry and scaly, the skui is thicker, and more rugose, than in eczema; and there are commonly some papulae scattered about, which, by their peculiar cha- racters, further distinguish lichen.— e. The vesi- cles of the early stages, and their presence around the patches of excoriation in the latter periods, as well as the less dry and less friable scales of chronic eczema, will generally distinguish it from psoriasis; in which also the skin is more elevated or thickened, and more fissured in parts not in- fluenced by the motions ofthe joints, than in any of the states of chronic eczema. 14. III. Prognosis.— In its acute form, this affection is generally of no great importance : but in many of its chronic states, it often be- comes most distressing ; and sometimes even em- bitters existence ; opposing, for many months, every known means of cure; and often returning after having been apparently altogether removed. When occasioned by mercury, especially if this mineral have been employed in large quantity, it may assume, as shown above, a most dangerous form; it therefore requires a guarded, and in some instances an unfavourable, prognosis, particularly when pectoral and nervous symptoms are present. 15. IV. Causes.— a. Eczema is most common in adults ; is somewhat more frequent in females than in males ; and oftener occurs in spring and summer, than in winter. Susceptibility of frame seems to dispose to it ; and there appears to be a predisposition in some constitutions, generally connected with vascular plethora, favouring its passage into a severe and chronic form.— 6. It is most frequently excited by solar or artificial heat; by the contact of either mineral, vegetable, or ani- mal irritants,—especially the oxides of the metals; by mineral or other powders ; by lime, alka- lies, dust, and want of cleanliness; by sugar, &c. I have seen it produced on the insides of the thighs and parts adjoining, by the contact of the leucorrhoeal discharge, and by the catamenial fluid. Draughts of cold water when the body is overheated, acid, acid fruits, pickles, and shell-fish, will also occasion it, especially in some constitu- tions. Blisters and plasters, and rancid oils or grease applied to the surface, are also among its usual causes. It sometimes, however, appears without any obvious reason ; at other times, it seems attributable to indigestible and unwhole- some food, to spirituous liquors, and similar errors in diet ; it being, in such cases, most obstinate. It is not contagious : but M. Biett supposes that it may be communicated in some cases, as when the exudation continues in contact with a healthy surface. He states, that he has seen it trans- mitted from, and to, the organs of generation, by sexual intercourse. The spedfic form is afwayi caused by the use of mercurials — internal or ex- ternal — but most frequently the latter ; and by exposure to cold during their influence. Whether or not the eruption, in such cases, may be in some measure produced by a change in the fatty substance used in oxydizing the metal, is very difficult to determine. 16. V. Treatment.—The remedies recom- mended by Willan and Bateman, viz. heating tonics and acids, I have found more generally injurious than beneficial. The treatment di- rected by Biett in his clinical lectures at the " Hrpital Saint Louis," and by his pupils, Rat- er, C v/.enave, and Schedel, in their works, is decidedly-more rational and successful.—A. The slighter grades of the acute disease are readily removed by simple refrigerants and emollient di- luents, with cooling aperients, and tepid bathing. But when the eruption is more extended, is ac- companied by smarting, or assumes the form of the Eczema rubrum or E. impetiginodes, tepid alkaline or sulphuretted baths — made by adding from four to eight ounces of the sub-carbonate of soda or of potash to the water of a whole bath, for an adult; or four ounces of the sulphuret of potash;—an antiphlogistic regimen; general blood- letting in young plethoric or robust persons; local bleedings in the vicinity of the excoriations ; and small doses ofthe nitrate of potash, with soda, in mucilaginous diluents; will be required in addition to the above more gentle means. Emollient and soothing applications should also be retried to. I agree with Mr. Plumb e, in avoiding all greasy applications ; and with M. Biett, in forbidding the use of sulphur, or repeated doses of mercury, in this state of the disease ; an antiphlogistic and soothing treatment being in every respect the most appropriate. I have prescribed with much benefit the sub-borate of soda, with or without the nitrate of potash, in emollients, in the acute form; and after the bowels have been evacuated, the nitrate of soda in similar vehicles. In all cases, the exciting causes should be ascertained and removed. 17. B. In the chronic states of this eruption, the antiphlogistic treatment recommended above should be employed, where it has been either neglected, or insufficiently tried. Purgatives also ought to be frequently resorted to, where the tongue is loaded and the evacuations unnatural, and repeated daily, until they assume a healthy hue. For this purpose a mercurial preparation may be exhibited at night, and a purgative draught in the morning. If there be signs of asthenia and a cachectic state of the frame, the purgative should be Of a tonic and stomachic kind ; the bark of the madar root, or tonic in- fusions, with the nitrate of potash, or with the mineral acids, being taken through the day, but not until mercurial medicines have been relinquished. Dr. Elliotson advises, in addi- tion to bleeding and a low diet, the exhibition of mercury until the mouth is affected; but the latter part of this practice does not agree with my experience ; the former I have always directed. It is chiefly when the excoriations are extensive, and the exudation copious, and after depletions have been employed, that adds seem to be indicated ; morbid secretions having been EDUCATION, PHYSICAL. 749 evacuated from the prima via. The infusion of roses, with sulphuric acid'and small doses of the sulphate of potash, or of quinine, or the infusion of cinchona with nitrate of potash, nitric acid, and the spiritus aetheris nitrici, is most conform- able to the treatment advised by other writers; but 1 have seen more benefit accrue from the de- coction or infusion of bark, with nitrate of potash and sub-carbonate of soda; from the compound decoction of sarsaparilla (the mezereon having been omitted in its preparation) with liquor potas- sae; and from the decoction of dulcamara, or of elm bark, with very minute quantities ofthe oxy- muriate of mercury, than from mineral acids. I have found Fowler's arsenical solution of ser- vice in some very chronic cases, but the affection often returned. It is requisite, in inveterate cases, that the diet should be strictly regulated, and confined chiefly to farinaceous food, and broth, with emollient diluents, in order to derive lasting advantage from any plan of treatment. 18. a. External means are especially requisite in most chronic states of the complaint. In addi- tion to those directed above, poultices or cold cream with a solution of the acetate of lead, or lint moistened in a dilute solution of this sub- stance, may be applied to the excoriated parts. When smarting and stinging are great, Dr. A. T. Thomson recommends them to be washed with a mixture of a drachm of hydrocyanic acid in eight ounces of the emulsion of bitter almonds. M. Guii.leminf.au advises the application of a solution of the nitrate of silver. When the ex- coriations are extensive, and the exudation copi- ous, the linimentum calcis, either alone, or with a little ofthe linimentum camphorae, will be very serviceable. The external use of camphor, in all such cases, is productive of advantage. Much benefit will often accrue from vapour baths, from tepid and warm alkaline, or sulphuretted baths; and, in the more chronic cases, from sulphureous fumigating baths: but this result will seldom be obtained — more particularly in plethoric and robust persons — until after morbid secretions have been fully evacuated, and bloodletting has been carried as far as circumstances will permit. Indeed, any of the numerous applications or combinations of moist heat, in the treatment of acute or sub-acute eruptive diseases, is more or less injurious, unless preceded by these measures. —When the eruption passes into a scaly and in- dolent state, some writers have prescribed blisters, or an ointment with the red precipitate, with the view of exciting a new action in the part; but these and similar means are inferior to the baths mentioned above. Ointments with the proto- \ ioduret (d j to 3 j-) or the deuto-ioduret (gr. x. to 3 j-) of mercury, promise, however, greater benefit. When the disease has been of long duration, the arrest of it should not be risked, un- less with the precautions of occasional vascular depletions, alvine evacuations, and the insertion of either an issue or seton, otherwise internal dis- order may supervene, or the eruption return,— illustrations of both these results having come before me in practice. 19. b. Mercurial eczema requires, according to the grade it assumes, a nearly similar treatment to the above. Biett judiciously prescribes blood- letting at the outset; Pe a r s o n , diaphoretics; and Bateman, frequent warm baths, with diaphoretics j 63* and opiates; and subsequently tonics and mineral acids. Dr. Mori arty, however, found opium to be a somewhat doubtful remedy. Mercury ought to be immediately relinquished, and a re- turn to it either avoided, or ventured on with caution. When the symptoms are severe, and the attendant fever of an adynamic kind, cam- phor, ammonia, the liquor ammonia acetatis, or pyroligneous add, or the chlorates, are the most appropriate remedies. Either of these should be associated with such other substances as may be appropriate to the circumstances of the case; and, when the discharge from the excoriated sur- face is either abundant or offensive, employed externally as well as internally; the strength of the patient being supported by appropriate means. 20. c. When convalescence from either of the states ofthe complaint is advanced, change of air, regular exercise, avoiding the ingestion of cold fluids when the surface is warm; a spare, lisht, and regular diet, with the occasional use of deob- struent or sulphuretted mineral waters; will generally tend to confirm the recovery. Bibliog. and REFER.—Aetius, Tetrab. iv. s. i. c. 128. —Paulus JEgineta, 1. iv. cap. 10.—Actuarius, I. vi cap. 8. —Sennert, Pract. Med. 1. v. par. i. cap. 2.—Brendel, De Inopinatis ex Mercurio dulci noxis, Opusc. vol. i. p. 69.— Schreiber, De Morbo Mercuriali. Erf. 1792.—B. Bell, On Gon. Vir. and Lues Venerea, vol. ii. p. 228.—Pearson, On the Effects of var. Articles of the Mat. Med. in Lues Vene- rea, 2d edit. cap. 13—Butter, Treat, on the Venereal Rose, 1799.—Moriai ty A Desci ip. of Mercurial Lepra, 8vo. 1804. —Spens, in Edin. Med. and Surg. Journ. vol. i. p. 7.— M'Mullins, in Ibid. vol. ii p. 37.— Rutter, in Ibid. vol. v. p. 143.—Chisholm, in Ibid. vol. viii. p. 296.—J. Frank, Acta Clinica, vol. iii. p. 22.; et Praxeos Med. L'niv. Praec. pars i. vol. ii. p. 177.— Marcet, in Med. and Chirurg. Soc. Trans vol. ii. art. 9.—Alley, On the Hydrargyria, or that Vesicular 1 ise se caused by Mercury, kc. Lond. 1810.— Mathias, On the Mercurial Disease, 8vo. 1811.—Horn, Ar- ch v. f. Med. Erfahr. Jahrg. 1812, p. 145.—Guillemineau, De I Emploi du Nit. d'Argent, fondu dans le Traite ". ex- terne de quelque Mai. kc 4to. Paris, 1826.—Raer, Traite des Mai. de la Peau, vol. i. p. 272.—Cazenave et Schedei, .^hrtge Prat, des Mai. de la Peau, p. 74.—Bateman, Svn. of Cut. Dis. by Thomson, p. 353 —S. Plumbe, Pract. Treat. on Dis. of the Skin, 3d ed. 1S32, p. 350.—W. C.Dendy. Treatise on the Cut. Diseases of Childhood, kc. Lond. 1827. p. 168. EDUCATION, PHYSICAL. — This subject is fully treated of in the article Age, where measures for the healthy developement of the organs and tissues, and for strengthening the constitution, are succinctly stated in connection with the epochs of early life in which they should be adopted (see Age, § 5—28.). In the article Disease, the numerous causes which impede, counteract, or entirely subvert, physical develope- ment and strength are described, and their mode of operation explained (see Disease, § 11 — 62.); and in the article on Infants, various ob- servations not comprised under the foregoing heads are adduced. Bibliog. and Refer.—Andry. Orthopadie, 8vo. Be I. 1774.—W'-rzer, Ueber die Physische Erziehung. Rvo. Bonn. 1797 —Wil/ich. On Physical Education Svo Lond. 1801.— Duncan's Annals 1801, p. 290.—Fothergill, Med. Observ. and Inq. vol. v. p. 160. - Underwood, On the Dis. of Child- ren with Directions for th ■ Manaeemen if Infa ts, &c , by Merriman 8vo. 8 h edit.— Syer, Treatise on the Manage- ment of Infants, &c. 8vo. lTl'l.—J.B Davis, Annals of the Universal Dispensary for Childr n with Rules for the Bod- ily Management of Infants, kc. 8vo. Lond. 18 l.—Haden, Piact. Observat. on the Management and Dis. of Children, with addit. Observ. by T. A/cock, 8vo. 1827. •- J Kennedy, On the M nae:emeiit of Children in Health and Dsease c. 12mo. 1.-25.—Rati r, Sur l'Education Physique des Enfans, 8vo Paris 1820.—Rullie.-, in Diet, de Med. t. i. p. 231.— Lachaise, in Archives Gi'ner. de Mi'-d. t. ix. \ . 180.—D'iffin, The Influence of Physical Education in producing Ueform- 750 ELEPHANTIA — Causes—Symptoms and Progress — Pathologt. ity ofthe Spine, &c. 8vo. Lond. 1829.—Roberton, Observat on the Mortality and Physical Management of Children, 12mo. Lond. 1827.—L. Stewart, On the Tendency to Dis- ease in Refined Life, kc 12mo. Lond. 1828.—J. Darwill, Instructions for the Management of Infants, kc Lond. 12mo. 1830.—M. Ryan, Lectures on the Management of Infants, &.<-., in Med. and Surgical Journ. vols. iv. and v. p ssim—See also the Bib/iog. and References to the arti- cles Age, Disease, and Infants. ELEPHANTIASIS OF THE ARABIANS. Syn.— Elephantia, Elephantiasis Arabum, Auct. Var. Hernia Carnosa, Prosper Alpinus. Glandular Disease of Barbadoes, Hendy. Bar- badoes Leg. Cochin Leg. Egyptian Sarco- cele, Larrey. Bucnemia Tropica, Good. Ele- phantiasis tuberosa, and Scrotalis, Alibert. Oelschenkel, Drusenkrankheit, Germ. Lepre tuberculeuse elephantine, Fr. Dal Fil, Arab. Elephant Leg, Elephant Disease. Classif.—7. Order, Tubercular Affections (Bateman). 6. Group, Leprous Affections (Alibert). 3. Class, 2. Order (Good). IV. Class, IV. Order (Author). 1. Defin.—Hardness, lividity, and great tumefaction of one or both limbs, or of the scro- tum,8cc, with an irregular glabrous, or scaly state of the skin ; endemic chiefly in warm countries. 2. Although this disease was first described by Rhazes, it has been very generally confounded, in modern times, with the elephantiasis of the Greeks, from which it is quite distinct. Its re- semblance, even, to the latter affection, does not sufficiently justify M. Alibert in arranging it under the same genus. It is seated most fre- quently in the lower extremities, but is also met with in the upper extremities, in the scrotum, the vulva, the breasts, and more rarely in other parts ofthe body. The countries in which it is most common are, Barbadoes, and all the West India Islands; various parts of South America; Egypt, and several parts of inter-tropical Africa; Ceylon, the neighbourhood of Cochin on the coast of Malabar, and other parts of Hindostan; Japan, and some districts of China; the Polynesian isles; and the provinces of Asturias and Castile, in Spain. Cases, however, occasionally occur in all the countries of Europe. According to Dr. Graves and Dr. Evanson, a variety of it is common in Ireland. I have seen one case in the Infirmary at Edinburgh; five in London, one of them very recently under the care of Mr. Mor- ley; and several, many years ago, in Africa, and on the Continent of Europe. 3. I. Causes.—a. The predisposing causes are not sufficiently known. It appears not to have been a very old disease in the West Indies, where it seldom occurs in Europeans. It is most fre- quent in Creoles and in imported Africans, and in places near the sea-coast. In the East Indies, it attacks only the natives. It seems in some instances hereditary, and in others derived from the habits or circumstances of the individual. — 6. The exciting causes are also obscure. Hil- lary and Hendy attribute it to sudden vicissi- tudes of temperature. It has been considered that the use of fermented beverages, especially those prepared in warm climates from the sap of several species of palm, occasions it, as acid wines give rise to gout, with swelling of the extremities, in this country. The remarkable case of it in both lower extremities, under the care ofMr.MoRLEY, is that of a man in good circumstances, who has lived well, and resided constantly in London 4. II. Symptoms and Progress.—The dis ease often commences without any premonitory signs; the patient experiencing rigors or chills, with nausea, headache, and intense fever, followed or attended by acute and burning pain, extending in the course of the lymphatics. Subsequently a tense, knotted, and hard cord, very painful to the touch, may be traced to enlarged glands in the groin or armpits. The surface of the part is soon affected by an erysipelatous inflammation, at- tended by a burning and smarting sensation, and by great tumefaction; the cellular tissue being implicated as well as the skin, which presents no appearance of vesication. These local symptoms are accompanied by fever, ardent thirst, burning heat of surface, &c, alternating with copious per- spirations. All these symptoms are diminished in the course of two or three days, and, excepting the tumefaction, disappear in a short time; but they return again after irregular intervals, each successive attack leaving the limb more tumefied and hard, until the disease reaches that pitch to which the term elephantiasis has generally been applied. After each of these seizures, the redness of the surface, and particularly that in the course ofthe absorbents, disappears; but the part at last becomes irregular, altered in colour, sometimes fissured or cracked, hard and elastic, pressure leaving no impression after it. The progress of alteration varies extremely — from a few months to many years. Sometimes the disease remains stationary for several years, and without any re- turn ofthe attacks now described. The cutaneous surface is occasionally pale, more frequently yel- lowish, of a dirty'hue or livid. It is often also scaly, resembling icthyosis, rugose, or fissured; is in some instances covered with soft vegetations; or with hard, horny excrescences; and is more rarely ulcerated. In other cases, the surface is traversed by enlarged veins; and very frequently enlarged or varicose veins are seen ramifying from the seat of enlargement, — a circumstance which evidently induced the Arabian physicians to notice this affection in connection with, and indeed as de- pending upon, a varicose state of these vessels. At a far advanced period, the hard and engorged glands sometimes suppurate, or even sphacelate; and more rarely, indolent abscesses, or deep-seated suppuration, with offensive discharges, supervene in the midst ofthe enlarged mass. When the disease is seated in the scrotum, this part often be- comes very remarkably enlarged. In Egypt and the East, tumours of this description are not infre- quent, and sometimes weigh from 30 to 80 lbs. Several of these have been removed in Egypt by Clot-bey. One of enormous size was lately operated upon in London, but unsuccessfully. M. Dupuytren met with an instance of this al- teration in the labia majora vulvae. 5. III. Pathology. — i. On dissection, the integuments of the part are found thickened and hardened:—1st. The epidermis is very thick, ad- herent, and fissured;—2d. The mucous layer is very distinct;—3d. The papillary body is greatly developed, and readily distinguished from the cutis vera or dermis, the papillae being elongated, en- larged, and prominent( Andral, Che valier) ;— 4th. The cutis vera is much thickened, it some- times being half an inch in thickness; — 5th. The sub-cutaneous cellular tissue is either thickened, the cellular areolae containing a semiliquid, gela- ELEPHANTIA — Diag nosis. 751 tinous matter; or it is hardened, presenting an intermediate state between a lardaceous and a scirrhous structure, and is more and more dense as it approaches the skin. The muscles under- neath are pale, thin, or softened. The lymphatic glands and vessels present evidence of disease, but not uniformly; and one or more of the prin- cipal veins are generally obstructed or obliterated, as observed in the cases inspected by MM. Bou- illaud and Gaide. 6. ii. Nature, fyc. —The structural alterations to which elephantiasis is strictly applicable, are evidently remote effects of various states of mor- bid action, which have either repeatedly returned, or have long continued in the diseased part. From the history of cases, and the changes observed on dissection, the skin, subjacent cellular tissue, the absorbents, and the veins, are evidently more or less implicated; but it is very difficult to as- certain which of these is primarily or chiefly affected. The principal characteristics of ele- phantiasis have manifestly resulted, in several instances, from disease of the absorbents, or veins, or both. They have also followed, within the scope of my own observation, a chronic affection of the skin, which has extended to the subjacent tissues, and, sooner or later, to either the veins or the absorbents, or perhaps to both. I was lately consulted by a female of middle age, who, during convalescence from a dangerous attack of con- tinued fever, more than ten years previously, ex- perienced hard and painful swelling of one of the lower extremities, depending on disease of the absorbents or veins, or both, according to the account she gave. When I saw her, the limb, below the knee, was very hard, and enormously swollen; and had all the characters of elephant leg; the skin being irregular, scabrous, livid, and fissured. I directed bandages, and the internal use of iodine; but after two or three visits, I saw no more of her, and consequently know nothing ofthe result. Some time previously, a similar case, as respects its origin and history, although not so severe, came before me. It had been of several years' duration; and had increased gradually after the acute attack in which it originated. The limb was hard, dark red, and livid in parts, some- what irregular, slightly scaly, and the veins above the tumefied part enlarged. The affection of the skin was here consecutive. Considerable advan- tage was procured from bandaging, and the in- ternal use of iodine; but the enlargement is not entirely removed. The patient is still under my occasional observation. More- than one of the cases I saw in Africa, seemed, on the other hand, to originate in a very manifest alteration of the cutaneous surface. 7. M. Alard considers elephantiasis essentially to depend upon inflammation of the cutaneous and sub-cutaneous absorbing vessels and lymph- atics. Dr. Musgrave also views it, as it occurs in the West Indies, as a consequence of inflam- mation of the lymphatics, the inflammation being accompanied with pungent heat, and with redness of the skin, and characterised by great tendency to metastasis. He states, that it usually betrays itself in the scrotum, the mammae, or in some part of the extremities, most frequently about the ancle, or high up the thigh; and, although at first circumscribed, it often diffuses itself over the limb. When the glands are not involved, painful and indurated cords can be traced to the nearest cluster; but, whatever may be its original seat, the patient is never secure, while the constitu- tional disturbance subsists, from a sudden retro- cession to some vital organ. He has seen it translated from the scrotum to the head; from thence, after a few hours, descend rapidly to the abdomen; again migrate to the chest; and return, perhaps, to the encephalon, and prove fatal there; or resume its more harmless situation, and there run its course. While occupying an internal viscus, it gives rise to the usual symp- toms of acute inflammation. Dr. Hillary and Dr. Musgrave view the local affection as a consequence of fever, which commonly precedes it for two days. Dr. Hendy, however, contends that the fever is symptomatic ofthe inflammation of the lymphatic vessels and glands. During the acute stage of the disease, either, perhaps, may precede the other; but it is most conformable with just views in pathology, to consider the local change as a consequence of the constitutional disorder; the advanced or chronic state being the result of repeated attacks of inflammation of the lymphatics or veins, and of the integuments, generally existing together, but often originating in, and Continuing more or less confined to, either. 8. Inferences.— According to the descriptions furnished by Towne, Hillary, Hendy, Mus- grave, Bouillaud, and Gaide, and to my own observations, this disease should be viewed— (a) as consisting of certain acute, as well as far advanced or chronic, states, generally connected with a bad habit of body, and each requiring an appropriate method of cure; and, (b) as arising — u. most frequently from inflammation of the lymphatic system and skin, particularly in warm climates; p. from inflammation and obstruction of the veins, in some instances, with irritation of the skin in various grades at an advanced period; and, y. from the extension of inflammation from the skin to the veins or lymphatics, in other cases. The tumefaction and hardness are necessary consequences of thickening of the cutis vera and sub-cutaneous tissue, with deposition of inspis- sated lymph in the. areolae of the latter, whether arising from chronic inflammation of these struc- tures, or from inflammation and obstruction of the lymphatics or veins, or from both these species of alteration. 9. IV. a. The Diagnosis of elephantiasis is very easy in the chronic and far advanced state. In the earlier stages, when commencing in either of the parts noticed above, it should be viewed as inflammation of that part, which, in countries where the disease is endemic, may be followed, if not properly treated, by the organic changes constituting its fully formed condition. When this takes place, the great tumefaction and hard- ness, and especially the circumstance of pressure not being followed by pitting, with the alterations already described (§ 4.), will sufficiently mark the nature ofthe disease.— b. The Prognosis is un- favourable, as respects the removal of the disease, when it is fully formed, although relief may be obtained, and persons may live very many years with it. But it tends generally to shorten life, and always to render it much less comfortable. When it is not far advanced, it may be nearly or altogether removed by treatment. The re- sult, however, will very much depend upon the 752 EMPHYSEMA — Pathology. habit of body, and vigour of constitution, of the patient. 10. V. Treatment.—i. Rhazfs and others of the Arabian phvsicians recommended, in the Acute stage oi elephantiasis, general bleeding, emetics, aperients, confinement to the horizontal posture, and spare diet, with cooling epithems to the part, and subsequently bandages. A similar treatment is very generally adopted in the East; and I believe that it cannot be much improved upon. Dr. Musgrave advises, in addition to the local application of warmth, and to febrifuge and purgative medicines, the exhibition of mercury until the mouth is affected, in order to prevent the metastasis ofthe disease, which, in the West Indies, is so common and dangerous; as well as the deposition of lymph, to which the hardness and swelling are chiefly owing. The employ- ment of a number of leeches or indsions, as re- commended by Mr. Copland Hutchison in erysipelas, followed by poultices, or other emol- lient applications, may also be resorted to with advantage at this period. 11. ii. In the Chronic stage, the above treatment will seldom be productive of benefit. M. Rayer, however, states, that general bleeding will be of service when the constitutional powers are not much impaired; and M. Lisfranc advises scari- fications, local bleedings, and compression. Band- ages, and frictions with various resolvent sub- stances, are more to be depended upon in the most chronic cases, and where the vital energies are too far depressed to admit of depletions. But even in these, active purging is indispensable. M. Alard records a case of twelve years' duration, that was cured by the repeated exhibition of ca- thartics. When the skin is in a state of irritation — is fissured, erythematous, or exudes a fluid concreting into scales or crusts—frictions, or even bandages, are not endured by the patient, and are not appropriate. In these, scarifications and blisters may be employed with the view of giving issue to the fluid infiltrated into the sub-cutaneous tissues. Cauteries and moxas have also been di- rected with this intention. Several writers advise douches of vapour — simple or medicated; and fumigating baths — either local or general. From my experience of iodine, I am inclined to think favourably of it in this disease. In one of the two cases, in which I employed it, manifest be- nefit was derived. It should be prescribed chiefly internally, as its external application is apt to in- crease the local irritation: and the bowels ought to be freely and frequently acted upon by deob- struent and stomachic purgatives. The limb should be kept as much as possible in the hori- zontal position. Amputation oi the affected part has been advised, and practised in a few instances with success. BlBLlOO. AND REFER.—Albinus, De Elephantia Java; Nova. Fr. 16J13 —Forestus 1. xxi \ obs. 26.—Towne, On the Dis most frequent in Barbadoes and West Indies, 8vo. Lond. 1726.—Putteney, in Philos. Trans, vol. lxii.—Kan- negiesser, De Eleph. Morbo Indiae Orien. endemio. Kil. 1752.—Henseller in Halter's Disputat. Chirurg vol. v. p. 463.—Hillary. On the Epidemical Diseases of Barbadoes, &c. 8vo. Lond. 1761.—Rapport des Commissaires dela Soc. Roy. des Medec. sur la Mai. Rouge, ou Eleph. kc. Paris, 17.5.—Conradi, in Arnemann's Magazin, b. i. p. 95.— Hendy, On the Glandular Dis. ol Barbadoes, kc. 8vo. Lond. 1784.—Revolat, in Bui. de la Soc. de Medecine. 1810, No. 1.—Alard, iVouvelles Observat. sur ['Elephant, des Arabes, 8vo. Paris, 1811., et de I'lnflamm. des Vaisseaux Absorb. Lymph, kc. 8vo. 2d ed. Paris, 1824.—Chevalier in Trans. of Med.-Chirurg. Soc. vol. ii. p. 71.—Good, Study of Med., by Cooper, vol. ii. p. 640.— Musg'ave, in Edin. Med. and Surg. Journ. vol. xxviii p. 4K.—Kennedy, in Ibid. ol. xiii. p. 54.—Gruves, in Dub. Hosp. Reports and Common vol. iv. p 54__Cazenave, in Journ. Hebdomad, t. iii. p. 146.— Martini et Hora k, in Ibid. t. iii. p 270.—Bateman, Syn. of Cut. Dis., by Thomsun, p. 427.—Bouillaud, in Archivei Grntx.de Med. t. vi. p. 567.—Guile, in Ibid. t. xvii. p. 533. — Andral, in Ibid. Mars 1827.—Rayer, Des Mai. de la Peau, kc vol. ii. p. 424.— azenave et Shedel, Abrege Prat, des Mai. de la Peau, p. 476.—Pierquin, Journ. del Progres des Scien. Med. vol. xi. p. 140. EMPHYSEMA. Syn. — "Eiitfrorua (from in- vna-, I blow), 'Eui icvnuT(,mh,Gr. Pneumatosis, Lat. Wind- geschwulst, Germ. Emphyseme Boursouflure, Fr. Enfisema, Ital. Inflation, Wind Dropsy. Classif. —3. Class, 2. Order (Cullen). 6. Class, 2. Order (Good). IV. Class, II. Order (Author). 1. Defin.— Soft, elastic tumefaction, occa- sioned by the presence of air, or of any other gaseous fluid, introduced or developed in cellular parts. 2. Although the sub-cutaneous cellular tissue is the most frequent seat of emphysema, yet other parts of the cellular structure may be also af- fected, either separately and independently, or iu connection with it. Those parts of this tissue, which are the most lax and the least loaded with fat, are most frequently and extensively inflated; and parts pressed upon by unyielding structures, or by the action of muscles, although they may give passage to the air, admit not of its accumu- lation.— J. P. Frank thinks that lean persons are mo.st liable to emphysema : this may or may not be the case; but there can be no doubt of these persons being more generally and exten- sively affected than those who are fat. When air is infiltrated into the cellular tissue, it may be diffused or conveyed, by the motion of contractile parts, to places remote from that at which it was introduced. 3. Emphysema may be divided, according to its seat, into—(a)External, or of the sub-cutaneous cellular tissue; and, (6) Internal, or of in- ternal viscera. The former may be more or less general, as regards that situation; the latter is commonly limited in respect of these viscera, but is often the source in which the former ori- ginates; the admission of air into the cellular tissue of the respiratory passages, by a solution of continuity in the lining membrane, or by rup- ture of the air cells, being the cause of the great majority of cases of external emphysema. It may also be considered, in connection with the modes in which it is produced—with reference, a. to its spontaneous evolution; and, b. to its origin in a solution of continuity in some part of a sur- face communicating with the external air — to its intrinsic, and extrinsic forms. The division into symptomatic or traumatic, and idiopathic or spon- taneous, is faulty; inasmuch as the spontaneous secretion of air from the blood into the cellular tissue, is merely a rare phenomenon contingent on far advanced states of disease; and as the in- troduction of air from without into this texture is not a symptom, but an accidental occurrence — is not a necessary or even a frequent consequence of a wound or injury, but dependent only upon certain circumstances or changes connected with such injury. — I shall therefore consider, firstly, the Intrinsic, or spontaneously contingent form • EMPHYSEMA — Intrinsic — Extrinsic 753 of emphysema; and, secondly, the Extrinsic, or the accidental traumatic conditions. 4. I. The Intrinsic, or Spontaneous Contin- gent Emphysema, is evidently dependent upon a more advanced state of the same general condition of the frame which gives rise to collections of air in other parts, and which, in its slightest grades, often occasions similar accumulations in the bow- els and uterus; the air in such cases being secre- ted from the blood, and consisting, most pro- bably, of certain combinations of hydrogen and azote, or of carbonic acid. Dead bodies be- come emphysematous from the gases disengaged during the process of decomposition; and a part which is gangrenous, is often also emphysema- tous from this change. But in these, the colour and cohesion of the parts are remarkably altered, and other proofs of decomposition are also pre- sent. In all diseases affecting the circulating fluid, as typhoid or adynamic fevers, especially those usually called malignant, and where the blood is contaminated by the absorption or intro- duction of morbid secretions or fluids, the exhala- tion of air into the cellular tissue and hollow viscera often takes place immediately after death; and, in some instances, it is observed in parts be- fore life is extinct. Morgagni remarked it in an advanced stage of fever following the repulsion of a chronic eruption (Epist. xxxvii. sect. 22.); Fabricius Hildanus notices its supervention after small-pox; and Wilmer, from the absorp- tion of putrid matters. I saw lately an instance of its appearance under the integuments in the vicinity of carious dorsal vertebrae, in a young lady. It was limited in extent, but elastic and crepitating. It is most frequently met with in warm and unhealthy countries, and in certain epidemics. I have seen it in the malignant fevers of warm climates; it has occasionally been notic- ed in epidemic yellow fever. Dr. W. Hunter (Med. Observ. and Inquiries, vol. ii.) and J. P. Frank (De Cur. Horn. Morbis, 1. vi. p. 38.) observed it very generally in an epidemic affect- ing horned cattle: the latter physician refers to its frequency in the last stage of an epidemic fever that raged in some parts of Germany in 1772, and of a similar fever that prevailed in Italy in 1789; the emphysema appearing about the neck and face, and sometimes extending to other parts of the body. Huxham (Med. Ob- serv. and Inquiries, vol. iii. p. 33.) remarks its connection with putrid fever and sore throat, as well as with scurvy; and records a case where it supervened, the patient recovering nevertheless. I saw a case of it in scarlet fever that terminated fatally, and another that recovered; and I agree with Huxham in considering its appearance about the neck and upper part of the breast as not rare in this and similar diseases. The only question as to these cases was, whether or not the air was evolv- ed or secreted from the blood, or was introduced from without at some part of the respiratory passa- ges in the manner about to be explained. Frank and some other writers likewise notice its superven- tion upon erysipelas, when the latter is prevalent in crowded hospitals. MM. Rullier and De- la roche have seen it occasioned by poisoning. 5. The intrinsic or spontaneous appearance of emphysema in such cases may be imputed to the partial decomposition or alteration of the circu- lating fluids consequent upon failure of vital power. This is evidently the case in some in- stances, especially when the swollen parts are discoloured, and when it comes on near the pe- riod of dissolution. But cases sometimes occur where no evidence of decomposition can be trac- ed, depression only of vital power being pres- ent. J. Hunter, Frank, Baillie, Home, Davy, and others, have adduced evidence of the evolution of air from the blood-vessels inde- pendently of such change. The experiments of Dr. Edwards prove that azote, and the other constituent gases of the atmosphere, are more or less absorbed into the circulation, and after- wards discharged from it, chiefly by the mucous surface of the respiratory organs and digestive canal ; and that these actions are regulated by the state of the vital energies of the system. It therefore cannot appear surprising that air should be extricated into the areolae of parts of the cel- lular tissue, as well as from mucous surfaces, in certain states of morbid vascular action connected with depressed vital power. Besides, we know that ah- is secreted into the sound or air-bladder of numerous species of fish. As to the chemical constitution of the air which is spontaneously evolved in cellular parts, we have very imperfect information. It is very probably nearly the same as that found in the digestive canal, and which consists chiefly of azote, carbonic acid, hydrogen, and certain of its combinations. In a case re- corded by M. Bally (Lond. Med. and Phys. Journ. for June 1831.), in which general em- physema occurred immediately after death, with signs of dissolution of the blood, the air was evi- dently ofthe last description; it having taken fire from the flame of a taper, and burnt with a blue and white flame; and the edges of the aperture through which it escaped having been consumed. Gaseous fluids may be evolved also in the cavities of the peritoneum and pleura: but generally in consequence of the decomposition of fluids, &c. previously affused in these situations ; although they may likewise be secreted by these surfaces; or common air may accumulate in the pleural cav- ities, owing to a communication with the vesicular structure ofthe lungs. (See Peritoneum, and Pleura.) 6. II. Extrinsic, or Accidental Traumatic Emphysema, sometimes appears in the course of various diseases, and from external injuries — of those maladies in which the respiratory functions become especially affected, more particularly the expiratory actions; and from laceration, rather than from puncture or incision, of parts, con- cerned in these functions. It always proceeds, unless in a remarkably rare form of this species, from the passage of common air into the cellular tissue, through a breach of continuity in some part of the respiratory apparatus. — (a) It may take place from rupture of the membrane lining the nasal fossa, or from wounds communicating with the lachrymal sac or duct; the air passing into the cellular tissue, upon forcibly blowing the nose. M. Meniere instances two cases of this description. J. P. Frank mentions its occur- rence from playing on wind instruments, whilst the insides of the cheeks are abraded or lacerated. M. Rullier states that the prisoners in the Bicetre at Paris produced it by puncturing the inside of the cheek, and forcing the breath into the puncture. 754 EMPHYSEMA — Extrinsic 7 (b) Emphysema is not infrequently occa- sioned by injuries ofthe larynx or trachea, espe- cially when the parts are lacerated by wounds perforating them, particularly when the external outlet is partially obstructed ; and by surgical operations on the neck (A. Burns). Rupture of the rings of the trachea will also produce it. Schreger adduces an instance of it from frac- ture of the thyroid cartilage. Ulceration in these situations, with sthenic vascular action, can hardly be followed by this contingency, as the lymph effused in the areolae of the surrounding cellular tissue quickly coagulates, and prevents the intro- duction of air. But when ulceration occurs in connection with asthenic action, emphysema may supervene; as the lymph thrown out in this state of the system is not coagulable, and consequently cannot prevent the air from being forced into the cellular structure. 8. (c) Emphysema often proceeds from rup- ture of the air-cells, and interlobular cellular tissue, the air escaping into the latter, and passing along it to the superficial parts of the body, ow- ing to the entire state of the pleura. When the rupture is confined to the air-cells, the air passes no further than the lobule .in which the lacerated cells are situated; but when the connecting tissue is also torn, the air escapes into it, and along its areolae, by the root ofthe lungs and mediastinum, until it reaches the cellular tissue of the throat, producing a crepitating and an elastic swelling above the clavicles, which is soon diffused over the face, chest, and trunk. This form of em- physema is occasioned chiefly by violent efforts, and straining, as lifting heavy weights (Hicks, Menilre), and child-labour (Hamilton, Hal- liday, Blagden, Bland, Simmons, &c), and by obstacles to respiration, as in hooping cough, pneumonia, bronchitis (Desbois, Ireland, &c), hysteria, &c, and in cases where a foreign body has fallen into the trachea (Louis, &c). I have seen it occur in the advanced stage of measles complicated with severe pulmonary affection. I lately attended a case of this description with Mr. Austin, in which the only matter of doubt was as to its having arisen spontaneously, or from the interruptions to respiration in the way now ex- plained. But the great difficulty of breathing that was present in consequence of infiltration of air into the interlobular tissue and mediastinum, readily pointed out its origin in this case, as it will in all others of the same kind. Dr. Drum- breck has recorded a similar instance, in which he could find no appearance of rupture in the bronchial lining; but it is in the vesicular struc- ture where it should have been looked for; and there it is manifested chiefly by the effects in ques- tion. The emphysema that is rarely observed in the course of diseases of the lungs characterised by dyspnoea, and of rabies, hysteria, &c, is evi- dently of the kind now described. 9. (d) Lacerations or perforations of the pleura, costalis and pulmonalis, and lung, by frac- ture of the ribs, and penetrating wounds, are the most frequent causes of emphysema. When the fractured end of a bone lacerates both pleurae, and the superficial portion of lung, the inspired air sometimes passes from the vesicular structure of the latter, accumulates in the pleural cavity, and is forced, by efforts at expiration, through the breach in the costal pleura, into the cellular tissue. Frequently, in consequence of the effu- sion of blood or lymph, the wound in the lung is in a short time so far closed as to prevent the further escape of air into this cavity; that which was effused being absorbed, and respiration be- coming less laborious. In this case, the emphy- sema soon subsides, owing to the absorption of the infiltrated air. But it occasionally happens that the wound in the lung continues open; and, upon each dilatation of the chest, air is drawn into the pleural cavity, and forced by each expira- tion into the cellular tissue of the thoracic parietes, until the inflation becomes enormous. When this occurs, respiration is remarkably laborious; inspi- ration is very rapid; expiration is slower, and, more forced, and is quickly succeeded by inspi- ration; the whole process being short, and ap- parently attended by an effort to expand the lungs, which are compressed by the air accumulated in the pleura. Emphysema is less frequently occa- sioned by penetrating wounds of the thorax and lungs, than by lacerations from fractured ribs; owing to the more constant effusion of blood or lymph from the wound in the lung after the for- mer than after the latter, as shown by the experi- ments of Hewson; and to the escape of the air from the pleural cavity by the external outlet in the thoracic parietes. It sometimes, however, arises from this cause; closure of the wound in the integuments, or some other obstruction in its more external part, occasionally allowing the air accumulated in the chest to be forced into the cellular tissue during expiration. Penetrating wounds of the chest very seldom produce emphy- sema, unless the lungs be wounded, and then the reason of its occurrence is obvious. But they may occasion it without any injury of the lungs, owing to the air being more readily drawn into the pleu- ral cavity during inspiration, than expelled from it during expiration. 10. (e) Ulceration of the pleura costalis and pulmonalis, and of the lung, has in rare instances produced emphysema, chiefly as a consequence of circumscribed empyema, that has opened into the bronchi. In this case, a communication is formed by ulceration between the cellular tissue of the thoracic parietes and the vesicular struc- ture of the lung, the surrounding pleuras being generally adherent. An abscess in the parietes of the chest likewise may point internally, and, hav- ing produced adhesion of the pleurae, burst into the lungs, and be followed by emphysema. But this last result will not occur in either of the above cases, unless the surrounding tissue is permeable by air, owing to coagulable lymph not having been formed in it. If this tissue be impermeable, then the air will only replace the matter that is evacuated, and give rise to circumscribed em- physematous swelling or swellings, as in a case recorded by Dr. Duncan (Trans, of Med. and Chirurg. Soc. of Edin. vol. i. p. 455.) A still more rare form is that following empyema which has opened externally through the thoracic pa- rietes. Ulceration may also take place in the lungs, and through the investing membrane, either from a vomica or tubercles, and the air be drawn into the cavity of the pleura; and, having accu- mulated there, forming pneuma-thorax, be forced through an ulcerated opening in some part of the costal pleura, into the cellular tissue of the tho- racic parietes, and be thence diffused to a greater EMPHYSEMA —Diagnosis or less extent over the body. Cases of this kind have been described by Kelly and Halliday. 11. (/) The rarest form of extrinsic emphy- sema is that consequent upon the escape of air, through a rupture or ulcer ofthe internal coats of some portion of the alimentary canal, into the sub-serous cellular tissue, and the diffusion of it through this tissue. Haller (Opusc. Pathol. vol. iii. obs. 31. p. 309.) met with a case of this kind in a female; and M. Marjolin (Archives Gener. de Med.t. xi. p. 112.) records an instance of it after a contusion of the abdomen which had ruptured the small intestines. MM. Chabert and Huzard (Observ. sur les Animaux Domest. fyc. 8vo. Paris, 1792.) state that this form is not rare in ruminating animals. 12. III. Diagnosis.—Emphysema ofthe sub- cutaneous cellular tissue is readily recognised by the uniform, light, elastic, and crepitating swelling constituting it. But it is often by no means so easy to determine the manner in which it has arisen. What has been adduced above on this subject will generally enable the inexperienced practitioner to recognise the different forms of its origin. 13. IV. Prognosis.—Our opinion of the ter- mination of emphysema will necessarily depend upon the causes that have produced it, and the state of the respiratory functions. The inflation is, in itself, but of little consequence, as air may be introduced to a great extent into the sub-cuta- neous tissue without giving rise to any serious re- sults,—unless, indeed, in a cachectic and asthe- nic state of frame, when puncture or laceration of this tissue, or of the integuments is very liable to be followed by gangrene of the part, as in the case recorded by M. Meniere. Aristotle and Pliny allude to a practice of inflating the sub- cutaneous tissue of animals, with the intention of rendering them speedily fat. Schulze states, that this process makes them first dull; and that the emphysema generally disappears in two or three days, after which they recover their spirits, acquire a voracious appetite, and, in a few weeks, become very fat. Haller, Gallandat, and Soehmerring, adduce similar facts in proof of the introduction of air into the cellular tissue being in itself pfirfectly innocuous; and Ac hard con- tends that the insufflation of carbonic acid gas into this tissue is the best mode of administering this fluid in the treatment of disease. Fabricius Hi ld an us (Cent. iii. observ. 18. p. 369.), Dio- nis, Ambrose Pare, and Keraudren (Bul- let, des Scienc. Med. t. iii. p. 422.), mention in- stances of the insufflation of air into the sub-cuta- neous cellular tissue of children, with the intention of exciting compassion, or of showing them as curiosities. Sauvages states, that a soldier was similarly inflated during sleep, to an enormous extent, without any further inconvenience than the impediment it occasioned to the respiratory actions. I therefore infer, with M. Breschet (Diet, des Scienc. Med. t. xii. p. 20.), that the prognosis in emphysema is altogether dependent upon the disease or injury on which it is contin- gent, and not upon itself, or even upon its extent; the degree to which the respiratory functions are disordered being the chief indications of danger, as evincing the effusion of air either into the sac of the pleura, or into the interlobular cellular tissue of the lungs. Spontaneous intrinsic era- - Prognosis — Treatment. 755 physema may be viewed as generally a fatal occurrence. 14. V. Treatment.—i. Oi Intrinsic Em- physema.—This species can be remedied only by restoring the depressed vital power, and removing the morbid condition of the local and general cir- culation on which it depends (§ 4, 5). The means most appropriate to these ends have been described in the articles Blood (§ 157.), and Debility (§ 38.), to which the reader is re- ferred. Scarifications and punctures have been recommended when the inflation is considerable; but there is great danger, in this state of disease, of gangrene following puncture of the skin, es- pecially if it be resorted to in hospitals, or in con- fined or ill-ventilated habitations. More benefit will follow gently stimulating and astringent lini- ments and epithems applied to the emphysema- tous surface and vicinity, and active stimulants, tonics, and antiseptics employed internally. 15. ii. Contingent Extrinsic Emphysema must be treated with strict reference to the nature of the injury that has occasioned it, and the state of the respiration.—When it has arisen from pene- trating wounds of any part of the respiratory ap- paratus, enlargement of the external wound will generally be requisite, in order that the air may have a direct external outlet. If it proceed from fracture of a rib, the application of a bandage may be serviceable, if the breathing be not materially oppressed; but when respiration is difficult, and pneuma-thorax is present, a bandage is generally injurious, by preventing that degree of dilatation of the lungs which is absolutely requisite to the continuance of life. If the pneuma-thorax from this species of injury, in addition to the external emphysema, be so great as to threaten suffocation, it will be necessary to make an opening directly into the pleural cavity as much as possible in the situation of the lacerated pleura costalis. If the inflation be so extensive as to prove, of itself, an impediment to the respiratory actions, and if the vital powers be not greatly depressed, and the frame not cachectic, several punctures, at a con- siderable distance from each other, may be re- sorted to. When the emphysema is more obvi- ously dependent upon rupture of the air-cells, and the escape of air into the interlobular tissue, &c, anodynes should be administered in order to lower the force of the respiratory action; and bloodletting practised, to lessen the quantity of blood to be acted on by the inspired air. In most instances of traumatic emphysema, the abstrac- tion of blood is requisite, unless the patient is sufficiently reduced by haemorrhage consequent on the accident. If inflation take place to a very great extent, punctures sufficiently deep to reach the cellular tissue may also be practised in this class of cases, but only in the circumstances and with the precautions now stated. M. Desbois advises, in preference to scarifications or punc- tures, the surface to be enveloped in cloths moist- ened with camphorated spirit, or a slightly as- tringent lotion. Unless the inflation by its extent greatly embarrass respiration, little need be at- tempted beyond the means now mentioned. In cases, however, characterised by great difficulty of breathing consequent upon penetrating wounds of the chest, or fractures of the ribs, or on ul- ceration, and which are generally preceded by pneuma-thorax, paracentesis of the chest some- 756 ENDEMIC INFLUENCES. times cannot be dispensed with. But it is neces- sary, previously to performing this operation, to observe and determine early and accurately, by auscultation and percussion before the inflation becomes extensive, in which pleural cavity the air has accumulated; because an opening made on the sound side, by causing collapse of the lung, would have a fatal result, as in a case recorded by Dr. Halliday. The seat ofthe injury, and the part at which the emphysema first appeared will generally indicate the situation where it should be performed. (For Emphysema ofthe Lungs, see Lungs—Emphysema of.) BlBLlOG. and Refer.—Aetius, Tetrabibl. iv. ser. iii. c. 2.—Oribasius, Svnops. 1. vii. c. 50.—Paulus AEgineta, 1. iv. c. 23.—Plater, Observ. 1. iii. p. 632.—Fabricius Hilda- mis, Cent. v. observ. 70.—Riv rius, Observ. cent. ii. n. 69. — Thuillier, Observ. Med. Pract. Paris, 8vo. 1732.—S-hulze, De Emphysemate. Hal. 1733. in Halter's Coll. DUs. Chir. vol. ii. n. 56.— £). Hoffmann, De Ae're Microcosmi Factitio. Tub. 1737, in Holler's Coll. Di<. Me I. Pract. vol. iii. n. 81. —Morgagni, De Caus. et S d. Morb. ep. liv. 37.—If. Hun- ter, in Med. Ob erv. and Inquiries, vol. ii. n. 2.—Leake, in Ibid. vol. iii. u. 4.—Russel, in Ibid. vol. iii. n. 36.—Hewson, in Ibid. vol. iii. n. 35.—Lloyd, in Ibid. vol. vi. n. 19.— Timmermann, De Emphysemate. Rint. 1765.—J. Hunter, On the Anim. CEconoiny, p. 207.—Hicks, in Med. Commu- nicat. vol. i. n. 13.—Simmons, in Ibid. vol. i. n. 14.—Bland, in Ibid. vol. i. n. 14.—Tondu. in Journ. de Med. t. xxv. p. 464.—Herbin, in Ibid. t. 1. p. 465.—Barriere, in Ibid. t. liv. p. 246.—Kelly, in Edin. Med. Comment, vol. ii. p. 427.— Koelpin. in Acta Soc. Med. Hafn. vol. i. n 23.—Thomann, Annales Wirceburg. vol. i. p. 176.—Baillie, in Trans, of a Society for Iuiprov. of Med. Knowledge, vol. i. n. 11.— Hebenstreit, I e Emphysemate. Lips. 1803.— J. P. Frank, De Cur. Horn. Morb. 1. vi. pars i p. 46.—Halliday, in Med. and Surg. Journ. vol. iv. p. 351.—Verheyen, Essai sur I'Emphyseme 4tc. Paris, 1809.—Schreger, in Horn's Archiv. Jan. 1810, p. 65.—Murat, in Diet, de Medecine, t. vii. p. 395.—Ireland, in Trans, of Coll. of Phys. of Ireland vol. iii. p. 112.—Dumbreck, in Trans, of Med. an I Chirurg. Soc. of Edin. vol. iii. p. 566.—Mtniire, in Archives Gen. de M.'d. t. xix. p. 341.—J. Davy, in Philos. Trans. 1823.— Bouillaud, Diet, de Med. et Chirurg. Pract. t. vii. p 112. ; Lond. Med. Gazette, vol. iii. p. 300.—Piedagnel, Journ. Hebdomad, de Mid. t. iii. p. 512. EMPYEMA. See Pleura — Diseases of. ENDEMIC INFLUENCE AND DISEASES. Classif. — General Pathology.— j&tiology. I. This subject is considered in many of its more general relations, in the articles Climate, and Disease; but there remain a few observa- tions, which do not fall under these heads, to be made at this place. The word endemic has usu- ally been applied to that influence exerted by the geology, soil, water, and air of a particular dis- trict or country, and by occupations and modes of living, upon the constitution and health of its inhabitants; and the more common and uniform results, or the consequent forms of morbid action, have been denominated endemic diseases. Al- though Hippocrates directed attention to en- demic influences in his Treatise on Airs, Waters and Localities, but little' notice was taken of the subject by medical writers until about the end of the seventeenth and commencement of the eighteenth century, when several works on the maladies prevalent in particular districts, and a few on endemic diseases generally, made their appearance. Before this period, however, C aius had offered some observations connected with en- demic influence in his work on the Sweating Sick- ness. A few remarks of the same kind are to be found in Andrew Borde's Dietary of Health; and in Ramesey's Origination of Worms, Src. The earliest work that treated of the general en- demic diseases of England was published in Lon- don in 1672, by CLAROMONTius.a native of Lor- raine, and dedicated to James Duke of Ormond, to whom he was probably domestic physician. In an address to the London College of Physi- cians, he apologises to that learned body for hav- ing encroached, he being a foreigner, upon a pro- vince which peculiarly belonged to them. The apology, as remarked by Dr. Duncan, was a tacit rebuke, and the severest he could have giv- j en, to a body which, even to the present day, has hardly interested itself in the advancement of medical science. In his enquiry, he enters upon the consideration of the extent to which venae- j section is required by the nature of the endemic | diseases of this country; and concludes that, al- though well-timed bloodletting is a judicious prac- tice,yet purging is, upon the whole, oftener re- | quired, and better adapted to their cure. After the treatise of this enlightened writer, others ap- peared, which comprised subjects connected with endemic influences and diseases, either incident- ally or specially. But sufficient reference will be made to them at the end of this article. 2. A reference to the topics treated of in the articles C l i m a t e ,and the Causation of Dis e a s e , will show that endemic influences are recognised rather by their effects than by positive characters, or manifest and demonstrative properties; and that they are results of several coincidences of physical phenomena and moral conditions, which often vary, and consequently give rise to modified effects. When we reflect that they are consequen- ces of the geology, soil, elevation, temperature, prevailing winds, vegetation, and the vicinity of wood and water; and not of these merely in their various states and associations, but of these in connection with the avocations, the modes of life, and the quality of the food of the inhab- itants, modified by moral agencies; we cannot be surprised at the diversity and importance of the resulting effects, and at the general uniformi- ty they frequently present, in certain circumstan- ces or combinations of these causes. In esti- mating endemic influences in relation to the re- sulting maladies, there are other agents, besides those now enumerated, that should be taken into consideration. The indolence or activity of the inhabitants; their privations and comforts; their states of filth or cleanliness; their habits of life, and employments; their ignorance and mental improvement; and their social, moral, religious, and political conditions; are most material ele- ments in the general amount of endemic caus- ation. It should not, however, be overlooked, that these diversified agencies act and react in developing, counteracting, or entirely removing each other; that the circumstances of locality will modify the moral and social conditions of its inhabitants; these latter, in their turn, giving rise to numerous collateral changes, and to impor- tant alterations even in the conditions of sur- rounding nature, as demonstrated by the inarch of civilisation and social improvement in both the old and new worlds. A casual view of the in- fluence of elevated and mountainous situations upon the physical and moral condition of its in- habitants, in relation to those of the plains, or of low, confined, and miasmatous localities, espe- cially within the tropics, and in some of the more southern countries of Europe, will sufficiently ENDEMIC INFLUENCES. 757 prove the importance of this subject; and if we take a closer view, so that the individual effects upon the frame and on the mind become appa- rent, the propriety of studying it in its practical bearings must be evident. 3. It was stated in the article Climate, that the constitutions of the natives of a particular country should be considered in many respects as products ofthe soil and climate, more espe- cially when its physical circumstances are differ- ent from those which most generally obtain on the face of this globe, and are productive of dis- ease in the more civilised races of our species. In such a country the human frame has become adapted to the climate to so great a degree as to render it a distinct variety from the rest of the species. We observe this in most low and swampy districts within the tropics, and emi- nently in Africa, many places of which could not be long habitable to others of the species constituted in any respect differently from the negro. The native frame, being thus assimilated to the climate, and modified by, and suited to, its endemic influences, is not injuriously impressed. by them. But when persons whose constitutions are formed by influences of a different, or even of a modified, character, migrate to a country differ- ently circumstanced, disease will sooner or later ensue. This susceptibility to endemic influences different from those to which the constitution has been accustomed, and by which it has been most remarkably modified, is evident in all the races of man, and is evinced more or less in all changes of climate;—by the inhabitant of elevated situ- ations, when he visits the low grounds and plains, even under the same latitude; by the native of nothern Europe, when he visits the shores of the Mediterranean — still more manifestly when he migrates to hot climates—and much more remark- ably when he resides in low and marshy inter- tropical districts; by the negro, the Malay, and the Hindoo, when they pass from the warm, moist, and low plains, on which they have been reared, to more elevated situations, or to temperate or cold countries; and so on, as respects all classes of our species, when the change involves a change also of the physical conditions of surrounding nature. This susceptibility is most remarkable in youth and early manhood, and diminishes gra- dually until age advances, and then the powers of life more readily sink when the change is made to a more unhealthy locality. 4. As endemic influences are frequently the result of certain conditions of locality inde- pendent of difference of latitude, or even of tem- perature; and often depend upon one or two circumstances connected with wood and water, or with the nature of the soil, or with elevation merely above the level ofthe sea; a change of situation apparently slight, may be essentially great, owing to these or other circumstances, and be followed by the injurious impression of the resulting influences upon persons not accustomed to them. The waters of large towns, that are, to a certain extent, impregnated by decomposed animal matters, seldom materially disorder the bowels of those accustomed to them, unless their impurity be very great, although they may other- wise affect the health; but they will seriously de- range the bowels of persons, even in the vicinity, who have not been in the habit of using them, as 64 shown by the different effects of the water of the Seine, at Paris, upon the inhabitants, and upon strangers in that city. Impurity of the water is, in all climates, an important source of endemic diseases, particularly of those seated in the digestive canal and circulation, as dysentery, diarrhoea, and fever; but the soil and vegetation, in con- nection with the extent to which they are watered, with high ranges of temperature, and with situ- ation particularly in respect of elevation, adjoin- ing acclivities, woods, &c, are the chief sources of these and all others of this class of maladies. The inhabitant of the high lands in the int jrior of Mexico is seldom affected by fever; but if he remain any time in the low grounds on the coast, in the same latitude, as at Vera Cruz, he is as liable to be seized by the malignant remittent endemic in that place, as the person who has migrated from Europe. 5. i. Ofthe chief Sources of Endemic Influence. — Low marshy places, and grounds subject to inundations, or saturated with moisture, and abounding with the exuviae of organic substances; thick woods and jungles, particularly in warm climates; argillaceous soils, and the deep alluvial earth in the bottom of valleys, on the banks of rivers, or near the level and shores of the sea or of large lakes, or the embouchures of rivers, es- pecially if subjected to a high temperature; are most productive of endemic diseases, which vary in character with the range of temperature, in connection with the degree of humidity, the ex- tent to which the soil is exposed to the direct rays of the suu, and the prevailing states of the at- mosphere. It may be inferred from the writings of the ancients, particularly those of Hippo- crates, Livy, Tacitus", Plutarch, and Dionysius of Halicarnassus, that the insalubrity of these places was well known to them, and that the means of removing and counteracting it were as well understood then as at the present day. Hippocrates, in his Epidemics, states that the city of Abydos had been several times depopu- lated by fever; but the adjoining marshes having been drained by his advice, it became healthy. The lake Averna, mentioned by Virgil, is, probably, a poetical exaggeration of the effects arising from marshes; and the deeds of Hercules, the metaphorical record of his success in removing these sources of disease. 6. Pools and ditches containing stagnant water, or nearly or altogether dry, after warm weather; and grounds used for the cultivation of rice; are also important sources of endemic influence. The former, in the vicinity of villages, frequently re- ceive animal exuviae, which render the exhala- tions from them much more noxious ; and the latter are especially injurious to white cultivators. The extent of disease proceeding from this source has been shown by Lancisi, Bailly, Mont- falcon, Irvine, Targioni, Grottaneli.i, and others, to be, in many places of Italy, Sicily, and Greece, so great, as to occasion more than two thirds of the average mortality. The exposure of a rich, wet, and low soil, abounding with vegetable matters undergoing decay, after repeat- ed irrigations and inundations, to a powerful sun, is the circumstance to which the insalubrity of I rice-grounds, and many other places, r-hiefly is I owing. In all intertropical regions, where the nature of the locality admits only of a rice culti- 758 ENDEMIC INFLUENCES. vation, Europeans are more or less subject to endemic disease; and although the dark races are much less liable to it, owing to the adaptation of their organisation and functions to this parti- cular soil and climate, yet they are occasionally affected by it in a slighter degree, and in a modified manner. Inundations, whether from the sea, or from the swelling of rivers, or from an admixture of sea with river water, render low grounds particularly insalubrious upon their be- ing exposed to the action of the sun's rays. Sea water, owing to the quantity of animal matter it contains, soon becomes offensive when it stagnates on a soil abounding with vegetable substances; and the inundated grounds and islets in the course, or at the mouths, of rivers, are generally left covered, when the waters subside, by mud and slime, which become an additional source of miasmata. The inundations by the sea, which have occurred in many places in Holland, have been the cause of much disease, upon the ex- posure of the soil to the sun during the following summer and autumn. 7. When low and moist grounds, and deep or rich soils, which have been covered by large trees or by water, are cleared, or exposed to the action of a warm sun, especially in a hot country, they emit more noxious emanations than in their un- reclaimed states; and they generally continue so to do, particularly during moist and warm wea- ther, and after long continued droughts following heavy rains, until they are completely brought under cultivation, and even for ages afterwards, in warm countries, near the level of the ocean, or the sea-shore;—circumstances which com- bine to make so many places in the West and East Indies productive of disease. Rich soils covered by large trees, and other bulky vege- table productions, are thereby protected from the action of the sun; and the exhalations which are given off from them, during warm and moist states of the air, are confined by these produc- tions to the situations which produce them. Dr. Rush states, that the endemic disorders of Penn- sylvania were converted, by clearing the soil, from intermittents and mild remittents, to bilious and malignant remittents, and destructive epi- demics; and that it was not until the soil had been subjected to cultivation for a number of years, that a tolerable degree of healthiness was procured. The district of Bresse, in the Lyon- nais, when well wooded, was comparatively healthy; but now, deprived of its woods, the low and wet soils being exposed more to the action of the sun, the exhalations from these, and from its numerous marshes and stagnant pools, are no longer confined by surrounding forest trees; and, consequently, endemic diseases of a severe cha- acter are very prevalent. Similar instances are to be found in the works of Deveze, Monfal- con, and Baili.y. 8. There are various circumstances connected with the production and diffusion of exhalations given out from the soil, that require attention from the medical practitioner. S6me of them are noticed at another place (See Dis ease,§ 55, 56.); but it seems fully established, that dead animal matter and exuviae in situations producing these exhalations, contribute most remarkably to their noxious effects. In warm countries, or in hot seasons in temperate climates, the places which are most productive of malaria, generally, also, abound the most in animal substances undergoing decomposition. The circumstances which render vegetation quick and luxuriant, generate immense swarms of insects and reptiles, the exuviae and dead bodies of which mingle with vegetable mat- ter in a state of decay, and give rise to miasms, particularly during moist states of the air, much more noxious than those resulting from vegetable matter alone. I have always considered the number of insects and reptiles, with which a place abounds, as more indicative of its insalubrity, than almost any other circumstance. .Malaria may be conveyed a considerable distance from its source, and be condensed in the exhaled vapour, when attracted by hills or acclivities in the vici- nity, and when there are no high trees or woods to confine it, or to intercept it in its passage. Owing to this circumstance, high grounds, near exposed marshes, are often more unhealthy than the places immediately adjoining, that are on a level with them. 9. There are no circumstances that tend more fo increase the sources of endemic influence, than high ranges of temperature, and calm states of the air. The effects of these vary remarkably with the quantity of humidity exhaled, and with the conditions of the air, in respect of horizontal and vertical currents, and of electricity. However productive the sources of malaria may be, and however- rapid the evaporation from them, the effects will be comparatively slight, if there be a quick renewal of the atmosphere passing over their surfaces, preventing the stagnation and concentration of the effluvia emitted by them. A high temperature, particularly with exposure of the soil to the sun's rays, penetrates to the lower alluvial strata; and, if it be attended by protracted dryness, occasions wide fissures in the upper strata, through which the moisture of the lower passes in the form of vapour, which is often more noxious than the emanations from a wet or marshy situation, especially when'the soil is argillaceous or absorbent. It is also indirectly owing to temperature, and the greater capacity it gives the air for moisture, that the marshes of warm, or even of temperate, climates are infinitely more unhealthy than the bogs and peat mosses of northern countries. High temperature and hu- midity, together with richness of soil, generate succulent plants which contain saccharine and oleaginous principles, and carbonaceous and hy- drogenous elements, with a portion of azote; and which rapidly pass, either altogether or partially, through the alternate processes of growth and decay. The vegetable productions, also, of hot countries, especially those which are most abun- dant, possess much less of the antiseptic princi- ples, with which those of cold climates abound, particularly tannin, creosote, the terebinthinates and their associated resins, the gallates, &c, which are found largely in the plants contributing to the bogs and peat mosses of the latter. Besides, the marshy places, and the surfaces of alluvial sods, in warm countries, contain more animal matters undergoing decomposition, than in cold and tem- perate regions; and are subject, in alternate suc- cession, to periodical rains and long droughts — are alternately inundated, and exposed to the direct action of the sun. Stillness of the atmo- sphere, by favouring the accumulation of malaria ENDEMIC INFLUENCES AND DISEASES. 759 in the lower strata, and in circumscribed limits, increases the injurious influence of this agent upon the human economy. Hence the danger of ex- posure to its sources during still and humid states of the air, at the close ofthe day, when it is con- densed in the descending moisture; or at night, or approaching dawn, when it is unrarefied by the solar heat, and not yet carried to the higher re- gions by the ascending or vertical currents of the atmosphere, and when the system is most expos- ed to its impression. During moist states of a warm atmosphere, also, the equilibrium of its electrical conditions is disturbed; the relative elec- trical states of this fluid, and ofthe body, is also considerably modified; and the changes produced upon the blood in the lungs, by respiration, are somewhat retarded. These effects are materially influenced by the situations and circumstances now adduced, and the respiratory functions re- markably impeded by them. 10. The good effects of a quick renewal of the air, in unhealthy places—of high winds, hurri- canes, and thunderstorms—in dispersing and al- together sweeping off the exhalations from the soil, and from decayed animal and vegetable matters, must be apparent. The more violent commotions of the air are the means employed by Providence to dilute, or entirely dissipate, those noxious agents, and to prevent their pesti- lential accumulation in the situations which have been described. It has been observed, especially in warm climates, and in hot seasons in temper- ate countries, that, when the air has been long undisturbed by high winds or thunderstorms, and at the same time hot and moist, endemic diseases have assumed a very severe, and even epidemic, character. Numerous facts illustrative of this have been adduced by Rush, Webster, Chisholm, Clark, Dkveze, Bancroft, and others. It is generally in hot miasmatous countries, and after prolonged seasons of drought and still states of the air, that tornadoes occur in hot climates, and thunderstorms in temperate countries, purifying and refreshing all the objects exposed to them, and preventing the occurrence of these severer forms of disease which would otherwise supervene. 11. Although the localities and related condi- tions described above are sources of diseases, chiefly in warm climates, and in temperate regions during hot seasons, they are not entirely destitute of influence in cold countries; their ill effects being generally in proportion to the height and duration of the summer temperature, and to co- incident circumstances. In northern temperate latitudes, and inland situations, the dryness ofthe air, especially during low ranges ofthe thermom- eter, and when the surface of the earth is sealed by an icy congelation, not only does the human frame enjoy a perfect immunity from terrestrial emanations, but it experiences an accumulation of positive electricity, aud increased activity of all the functions. The changes produced by respiration are most complete; the nervous and circulating systems evince increased tone; ani- mal heat is rapidly generated to replace that car- ried off by the surfaces, the body acquires the phlogistic diathesis, and diseases present the stheuic forms. 12. ii. Effects of Endemic Influence.—A. The exhalations from the situations now described, at the commencement, during, and after heavy rains I and moist states of the air, generally occasion agues, dysentery, scurvy, scorbutic dysentery, enlargements of the liver and spleen, cretinism, scrofula, rickets, &c; and if the temperature be high, the various forms of remittent and conti- nued fevers, in addition to these. The same lo- calities during warm and dry seasons, and after protracted drought, produce bilious and malig- nant fevers, of a remittent and continued type, cholera, diseases of the liver, and inflammations of the alimentary canal; the intermittent and remittent fevers prevalent during the colder sea- sons, passing into a more continued type, and bil- ious or malignant form, after great or continued heat. This change in the character of the en- demic with the temperature and seasons, was well illustrated by the history furnished by M. Kirchoff (Journ. Compliment, des Scien. Med. Jan. 1827.), of the diseases following the partial inundations by the sea of some parts of Holland, in the winters of 1825 and 1826. He states that the waters used for domestic purposes were brackish; and the ponds and ditches, which were usually limpid during the spring, became greenish on the surface, and offensive. At this time, agues pre- vailed amongst workmen exposed to the exhal- ations from these sources. As the summer ad- vanced, and the waters were more completely drained off, the effluvia were more concentrated, and fevers assumed a remittent type. In the months of August and September, fever presented more of the continued character, with periodical exacerbations, particularly of the pains in the head and back, and closely resembled the endemic of low and moist situations within the tropics,— the circumstances occasioning it having been in every respect similar. In the majority of cases, the liver was affected. It has been shown by writers on the fevers endemic in Hungary, that agues are most prevalent during spring; and that remittents, continued fevers, and dysentery, be- come more common during summer and autumn. Indeed, endemic fevers are modified, from the more simple form of ague to the most malignant remittent or continued type, by the particular circumstances in which they originate,— as the miasms become more concentrated, or consist more of the effluvia of decayed animal substances, ■—by the warmth of the season and climate,— by the humidity and dryness of the air, — and by the constitution and predisposition of the patient. As these vary, so does the particular character of the disease. Intermittents present every type, and various complications; and re- mittents, numerous grades and forms—the bilious or gastric, the inflammatory, the bilious inflam- matory, and the asthenic or malignant. Con- tinued fevers, also, assume a mild, an inflamma- tory, a gastric, or an adynamic form. Not infre- quently, the intermittent passes into the remittent, and this latter into the continued type; and either may be followed by dysentery. Each of these states of fever may be simple or complicated; the principal local affection being different, as well as diversified in kind, in different cases, and ap- pearing sometimes so early as to seem the primary disease, frequently in the advanced progress of the fever, and occasionally not until its latter periods. Either of these forms of fever may com- mence mildly and insidiously, and yet soon pass into dangerous local derangement and disorganis- 760 ENDEMIC INFLUENCES AND DISEASES. ation: others may begin with great excitement, rapidly terminating in exhaustion and depravation of the circulating and secreted fluids; some pre- sent great depression from the beginning, the powers of life never rallying throughout, or very imperfectly, with an unnatural state of all the secretions and soft solids, and a tendency to dis- solution of their cohesion, which rapidly advances, especially in warm countries, as soon as respi- ration ceases. In certain circumstances, particu- larly when great vicissitudes of temperature and weather cooperate with the strictly endemic causes, or with improper living, impure water, &c, dy- sentery becomes as prevalent as fever, or entirely usurps its place; or the fever assumes a dysen- teric character, or passes completely into dysen- tery; this latter malady producing even a greater rate of mortality than fever itself. (See art. Dysentery.) 13. B. Whilst rich soils, and warm, low, moist, and marshy situations, are productive of disease affecting chiefly the circulating and secreted fluids, and the abdominal viscera, by lowering vital power, especially as manifested in the nervous Bystems; elevated, cool, or temperate and dry districts favour the developement of vital energy, especially as expressed in the nervous, muscular, and circulating systems, and in the thoracic vis- cera; and produce diseases of a phlogistic char- acter, as sthenic inflammations of the lungs and circulating organs, of the membranes of the brain, and of the other serous and fibrous structures, haeniorrhagies, rheumatism, and fevers of an in- flammatory type.—These diseases, however, al- though the most prevalent, can scarcely be said to be endemic in these latter localities, they being much less frequent than the maladies of the former situations. It should, however, be recollected that the respective endemic influences of districts are not so deleteriously exerted on the native in- habitants, as upon those who have lately removed to them; and that, though they may affect the constitutions of the former class, and give rise to certain diseases, in preference to others, yet those diseases are not so acute or violent in them, as in the latter. This circumstance is well illustrated by what is constantly observed in warm countries productive of terrestrial emanations. There, the native inhabitants are either scarcely affected by them, or are liable only to agues, bowel com- plaints, enlargements of the spleen, or slight ail- ments referrible to the large secreting organs, excepting on occasions of these exhalations be- coming more concentrated or energetic than usual. But persons who have removed thither from healthy localities, in cold or temperate climates, sooner or later are seized by fever, generally of a remittent, or continued type, often assuming an inflamma- tory or malignant form, and frequently associated with violent local determinations; and it is not until after the frame has been assimilated to the climate by such attacks — usually called the sea- soning fever — that agues, dysentery, and the milder forms of disease, appear in such persons. On the other hand, the inhabitants of low or mias- matous situations, who have removed to elevated and mountainous districts, are much more liable to diseases of the lungs, to rheumatism, and to inflammations of a sub-acute or chronic form, than the natives of these latter places; and if the change at the same time involves a change from a high to a low temperature, the liability to pect- oral maladies is still further increased. 14. C. When persons have migrated to a coun- try abounding with the sources of endemic diseas- es, a period of longer or shorter duration, accord- ing to the activity and concentration of the mala- ria, and the predisposition ofthe individual, usually elapses before they are attacked by these maladies. In Rome, and other malaria districts in the south of Europe, as well as in many of those in the eastern and western hemispheres, where the ex- halations are not very active, several months, or even a year or two, pass before the unaccli- mated are seized by fever, unless the exposure and predisposition (see Disease—Predisposing Causes of) be great. Whilst in many situations, where the emanations are more concentrated, or consist of an admixture of those given off both by vegetable and by animal matters in a state of decomposition, particularly in warm climates and seasons, the first exposure to them is often pro- ductive of the most active forms of fever, and in a very short time after the exposure occurs. This is commonly observed in respect of young un- seasoned sailors and soldiers, who, coming from a pure air, in a state of high predisposition, are often subjected to these emanations in their most active states. Persons arriving in warm mias- matous districts, from temperate and healthy places, are affected with a celerity and severity generally in proportion to the fulness of their vascular systems, to the rigidity of their fibres, and to their nearness to the epoch of early man- hood; but various exceptions to this occur, arising out of the habits of individuals, the susceptibi- lity of their nervous systems, the extent of their exposures, and the states of their minds and moral emotions. 15. D. Although the white races of the species will live to an advanced age in warm districts productive of endemic disease, especially if they have removed thither after the constitution has been fully developed; yet their offspring will very seldom reach maturity, or survive the epoch of childhood, if they continue to reside in such situations; or, if they arrive at manhood, they will very rarely reach an advanced age. Dr. Jackson states, that white persons, born and residing in the more unhealthy districts of Lower Georgia, seldom live to forty; and that, at Pe- tersburgh, in Virginia, they rarely reach twenty- five. He saw, at this latter place, a person who was only twenty-one; and although he had never been confined by severe sickness, yet he was weak and decrepit: so injuriously does endemic influence operate upon the constitutions of the white variety, even when it fails of inducing acute disease. Bruce records similar instances among the white natives of the banks of the Nile, in Abyssinia; and other illustrations have been ob- served by myself in some parts of Africa. Children born of European parents in India require to be sent to Europe to acquire due maturity and strength; for they very seldom arrive at puberty in India. The case, however, is different when one ofthe parents belongs to the indigenous inhabitants; but there can be no doubt, that, were a colony of the white races conveyed to the low miasmatous localities within the tropics or in more temperate regions liable to very hot seasons, it would, in a very few generations, become extinct, if intermarriage did ENDEMIC INFLUENCES AND DISEASES. 761 not take place with the natives, or if it were not I coverings on the head (Kerckhoffs, Larry, supplied from time to time from more salubrious Alibert, &c). There appears to be frequently places. Whilst a change to a more unhealthy : an hereditary predisposition to it; but the cause climate is best endured by those who have arrived i now assigned is evidently the most influential in at full maturity, change to an equally or a more producing it, assisted by the use of unwholesome healthy climate is especially beneficial to very j water (Vicat). It is most common amongst the young persons, unless in the case of removal of I poorest classes. According to Dr. L. Iyerck- individuals belonging to the dark races to a tern- j hoffs (Med. Trans, of Coll. of Phys. vol. vi. perate country, from the hot climate in which they p. 27.), it is not infectious (see art. Hair).— are indigenous. j (d) Tarantulism (see Chorea, § 18.) was for- 16. E. Besides fevers, dysentery, and the slow I merly endemic in Apulia, but is now by no means bli«*ht ofthe constitutional powers, the localities so frequent(LAURENTandMF.RAT). Thisspecies above described induce, in the white races, dis- of irregular convulsive or hysterical affection, in eases of the spleen, liver, and pancreas, both in which the moral emotions seem more disordered unassociated forms, and as complications with than the physical powers, was imputed by Sir T. fevers and dysentery. Among their less obvious i Browne, Boyle, Kircher, Baglivi,Mead, effects may be enumerated scurvy, and foul ulcers and Sauvages, entirely to the bite of the taran- of the lower extremities. The great prevalence j tula spider, which probably is an exciting cause, and obstinacy of these latter in miasmatous situ- j in certain states of the nervous system, although ations have not been sufficiently attended to, al- j neither the only nor the chief cause. Cornelio, though Baglivi had noticed the circumstance in Serao, and Cirillo, physicians in Naples, and Rome, and Cleghorn in Minorca. Indeed, in M. Nollet, have taken juster views of its origin; all low places productive of malaria, injuries ! and refer it rather to the state of the nervous and sores of the legs heal with great difficulty, , system in connection with the moral emotions, whilst those of the head recover rapidly. Hippo- \ than to this insect. Indeed, it is extremely pro- c rate sand Celsus seem to have been aware of j bable that it is often feigned, or frequently occurs, this fact. They both notice the frequent association without any such accident as that to which it is of indolent ulcers ofthe legs with enlargement of \ so commonly imputed; for very nervous and fan- the spleen,—which is remarkably common among ciful females may persuade themselves that they the cultivators of rice-grounds, both in the south ' are stung by this insect, in order to account for of Europe, and in other quarters ofthe globe. i their ailments, conformably with the vulgar opi- 17. There are some situations, which do not ! nion, and may thereby induce that form of irre- fall within the description given above, produc- j gular chorea or hysterical affection to which the tive of diseases almost proper to them; or which term tarantulism or tarantismus has been applied. are comparatively rare elsewhere; as cretinism, \ M. Merat (Diet, des Sdences Med. t. liv. p. bronchocele, plica or matted hair, Guinea worm, i 345.) infers that the inhabitants of Apulia, owing tarantulism, pellagra, fyc. These depend in great to situation and climate, are liable to nervous measure on the water, in conjunction with modes and spasmodic affections; and that, among others, of living, and various other circumstances.— this is apt to supervene,— from their ardent and (a) Cretinism (see this article) is endemic in the I choleric dispositions, and their love of dancing deep ill-ventilated valleys of the Alps and Py- and music. In Calabria and the Apennines, where renees, in Carinthia and the Vallais, in the moun- I chorea and convulsive affections are common, tainous parts of Tartary and China, in some parts tarantulism also occurs (Ferrus).—(e) The of the south of France, and in Salzbourg. It Guinea worm (Dracunculus), the long thin seems not to have been unknown in this country, worm which is sometimes found in the inhabitants two or three centuries ago, in the situations where of certain localities, generally under the integu- bronchocele and rickets — very nearly allied ments, and so named from the circumstance of its diseases — have coutiuued to be common.—(6) ! having been first accurately observed in the natives Bronchocele is very frequent in the situations of Guinea, is now seen in other countries. It now particularised, especially in the valleys of [ appears from Plutarch to have been met with the Alps, where it was equally prevalent in the in the inhabitants near the Red Sea. It occurs times of Pliny and Juvenal; in Derbyshire; | among the negroes in most ofthe low marshy sit- in Behar, and some other mountainous districts of ! uationsof intertropical Africa (Welsch, Bruce, northern India; in similar situations in Java (S. | Park, &c); in the slaves, and sometimes in the Raffles) and Sumatra; in Bambara, in the whites, in the West India islands (Chisholm, course of the Niger (M. Park); and in Mexico, Thomas, &c); in Bombay, and along a great and some other parts of South America (Hum- j part of that coast, as well as in some other mari- boldt). It is most prevalent in females after pu- time districts of India (M'Grigor, Milne, H. berty; and is, in my opinion, often connected with Scott, Grant, &c); and in the islands of the interrupted or irregular catamenia.—(c) Plica, or ' Persian Gulf (K^mpfer).—It is observed chiefly matted hair, is not noticed by the ancients, and during the months of November, December, Ja- it is doubtful when it first appeared — probably , nuary, and February, in both the East and West some time between the thirteenth and fifteenth Indies. M. Dubois found, in parts of the Car- centuries. It is most common in Poland and natic and Madura, more than one half of the Lithuania; but it is met with occasionally in inhabitants of some villages affected by it. Dr. Transylvania, Hungary, the southern parts of Chisholm (Edin. Med. and Surg. Journ. vol. Russia and Tartary, and more rarely in Switzer- | xi. p. 145.), Dr. Smyttam Trans, of Med. and land, Belgium, and Prussia : but it is not so fre- Phys. Soc. of Calcutta, vol. i. p. 179.), Dr. An- quent, even in Poland, as it was a century ago. It derson, and several others, state that it is met proceeds chiefly from want of cleanliness, especi- j with cliiefly in those who use wells made in argil- ally in respect of the hair, and to wearing too warm laceous soils, impregnated with salt or percolated 762 ENDEMIC DISEASE: by sea water. M. Dubois adds, that the inha- bitants of villages who take water from one well are subject to this worm, whilst those at the dis- tance of only half a mile, who resort to a different well, are not affected by it. Other writers, in addition to those named above, agree in ascribing it to brackish waters containing the ova or embryo of this worm. The circumstance of this animal havingTbeen rarely found out of the human body has induced Dr. Milne (Edin. Med. and Surg. Journ. No. 106. p. 112.) to suppose that the sub- stance taken for it has been a diseased lymphatic vessel; but the evidence of its independent exist- ence furnished by Dr. H. ScoTT(MetZ.-C/iir. Rev. vol. iv. p. 182.) and Dr. R. Grant (Edin. Med. and Surg. Journ. No. 106. p. 114.) has set the matter at rest. As to the manner in which this worm becomes lodged in the sub-cutaneous cel- lular tissue, much doubt exists. It must either insinuate itself through the skin from without; or its ova escape the action ofthe alimentary juices, and pass along with the chyle into the circulation, and thence into the cellular tissue, where, having attained a certain growth, it excites the irritation preceding its expulsion. But if it pass by this latter route, how is it that it is never found in the cellular or other parts of internal organs, where it may be expected to produce dangerous, if not fatal, effects ? 18. F. In low, moist, and cold districts, liable to frequent vicissitudes of weather and temperature, catarrhal and rheumatic affections, croup, bron- chitis, scrofula, rickets, and tubercular diseases, are more or less prevalent; and in those similarly situated on the sea coast, where the inhabitants live chiefly on fish—particularly on stale or dried fish, or the grey kinds —chronic eruptions on the skin are common. In large towns and cities, where a confined and impure air cooperate with the anxie- ties of business, the exhaustion of mental exer- tion or of dissipation, the luxuries of refinement, the conflict of the passions, and the excitement of the different moral emotions, disorders of the nervous system frequently implicating the mani- festations of mind, are more common than in the country, and much more so than in imperfectly civilised states of society.—My limits will admit only of a simple reference to other endemic dis- eases — to the prevalence of trismus and tetanus in the West Indies; of elephantiasis ia these islands, and in the East, as well as in Africa; of the yaws in the negro race; of the pellagra in Lombardy and the Milanese; ofthe beriberi in the East Indies; of hepatic colic (see Colic, § 20.) in Spain and the W"est Indies; and of ophthalmia in Egypt. Some of these may be imputed to obvious physical causes; as the ophthalmia of Egypt to the reflected heat, and the dust in the air; or pellagra and some cutaneous diseases, to dirty habits and unwholesome food : but there are others that cannot be explained without ascribing them to the cooperation of a variety of circum- stances, as shown in the articles on these maladies. In illustration of the influence of occupations in producing a certain train of morbid actions in those similarly circumstanced, it may be stated, that amongst the children and young persons employed in cotton mills, more especially in Manchester, chorea, which is comparatively a rare disease, is one of the "most common; scrofula, tubercles, and debility in all its states, being — Prevention of. likewise very prevalent; and that, in the some- what older work-people, chronic rheumatism, in all its forms, is remarkably frequent. The protracted periods of occupation in a very hot and moist air, and generally in a standing pos- ture; the sudden exposure to a cold atmosphere on every occasion of leaving the factory; and the want of due sleep, of exercise in the open air, and often of sufficient nourishment, independently of various moral causes; sufficiently explain the endemic prevalence of these diseases in the large manufacturing town now mentioned. (See Arts and Employments — as Causes of Disease.) 19. iii. Of the Mode of Operation of Endemic Influence on the Economy.—The endemic causes productive of the more acute and malignant dis- eases were supposed by Cullen to be direct se- datives, not merely lowering vital power, but also inducing spasm of the extreme capillaries; and that, if the vital energy of the system is not en- tirely overpowered by them, reaction supervenes in order to overcome this spasm, and thus fever be- comes developed. Other pathologists suppose that marsh effluvium acts as a stimulant or irritant; and that the debility which it obviously occasions, is either consecutive, or a state of exhaustion. Neither of these hypotheses accounts for the whole phenomena which diseases, arising from this cause, evince throughout their course, although either explains many of their symptoms. That malaria depresses vital power, contaminates the circulat- ing and the secreted fluids, and weakens the vital affinity or cohesion of the soft solids, is shown by its more immediate, as well as by its consecutive, effects upon the living body, and by the fact of dead animal matter running faster into putrefac- tion in situations where it abounds. Its septic operation on sores and wounds is often evinced during life. It has been repeatedly proved, that substances fabricated of silk, woollen, and even of cotton and flax, exposed to marsh exhalations, very rapidly undergo decay; silk and woollen becoming putrid, and cotton and linen assuming a dingy or yellow hue, and afterwards losing their cohesion. These effects are generally rapid aud complete, in proportion to the moisture and warmth of the air, and the concentration of mal- aria in it; and so well are they known, M. Mon- falcon states, that they are generally recognised by the more intelligent inhabitants of Italy and the south of France, as indications of the insalu- brity of particular places and seasons. 20. iv. Ofpreventing the Production of Endemic Causes, and of counteracting their Effects.—A. Of preventing the generation of malaria. — (a) Draining marsh grounds is one of the most effi- cient modes of preventing the formation of ma- laria; but it should be recollected, that uncovered drains and ditches are fruitful sources of endemic influence.— (b) Embankments thrown up against inundations from rivers and the sea, are also im- portant means of prevention; but, if they be not quite adequate to the purpose, they may aggra- vate the evil, by preventing the water from re- tiring with sufficient rapidity.—(c) In situations admitting of neither of these means being employ- ed, then advantage will often be derived from cov- ering them entirely with water; for lakes do not exhale miasmata until after the mud and soil of their bottoms and sides have appeared above the surface. Senac states, that the outskirts of a ENDEMIC DISEASES —Prevention of. 763 large town became unhealthy as soon as the mud at the bottom of some adjoining morasses was ex- posed to the sun and air; but that disease dis- appeared when they were completely inundated. Dr. Rollo mentions, that mild intermittents pre- vailed in St. Lucie during the rains, when the pools and marshes were filled; and that danger- ous fevers appeared after their slimy surfaces be- came exposed and completely dry. .Mr. Annes- ley records similar facts in relation to various places in the East Indies. The ditch round the ramparts of Geneva was once drained, and sick- ness prevailed in the vicinity, but disappeared when it was again filled. And the water-courses and beds of rivers that are dried up in summer, par- ticularly in warm countries, and thereby become sources of malignant fevers, are quite innocuous when filled (Ferguson, &c).—(d) Clearing the soil from its more bulky vegetation will be benefi- cial only when an assiduous cultivation is adopted, without the necessity of having recourse to a very abundant irrigation. In many circumstances, however, this measure will greatly aggravate the insalubrity of a district, as shown above, especially in respect of low swampy places within the tropics, or near the sea. Facts illustrative of this, have been often observed in both the old and new worlds.—(e) Protecting the soil in which large cities are built, particularly when situate near the embouchures of rivers, &c, from the action ofthe sun, by a closely laid pavement; intersecting the strata of earth by large deep sewers, conveying the exuviae and other impurities beyond the reach of the inhabitants, and in such a way as to pre- vent the escape of emanations from them, in the midst of a dense population; and removing places of sepulture beyond the outskirts of cities and towns; are measures ofthe utmost importance to the health of the community. 21. It is established beyond a doubt, that the narrow winding streets of towns built in low situa- tions, or in the vicinity of marshes, are, especially when the houses are high, actually conducive to health; inasmuch as the exhalations transported from thence, have a less ready access to all parts of them, the horizontal currents of air being more completely intercepted, by the nearest buildings : also, when the streets are narrow, and the houses high, the sun cannot act upon the soil, which ne- cessarily becomes saturated with animal exuviae, unless deeply intersected and purified by drains and sewers. The importance of this consideration was not overlooked by the ancients, as appears from the remark of Tacitus, on the rebuilding of Rome after its destruction by Nero. "Erant tamen, qui crederent, veterem illani fonnam salu- britati magis conduxisse, quoniam angustia: itine- rum,et altitudo tectorum non perindesolisvapore perrumperentur. At nunc patulam latitudinem, et nulla umbra defensam graviore aestu ardescere." (Ann. 1. xv. 4:5.) 22. B. Whilst the above measures have refer- ence chiefly to the prevention of the formation of terrestrial exhalations, there are others that may be employed to confine them to the sources whence they issue, when the former means are ineffectual, or cannot be put in practice. It is very proba- ble that many places, the insalubrity of which was recognised and guarded against by the an- cients, have actually become more unhealthy in modern times, owing to the accession of alluvial soil washed down from the higher grounds in the vicinity; to the accumulation of decayed organ- ised matter and mineral detritus at the mouths of rivers, and in the bottoms of lakes, which have been thereby converted into marshes; to the neglect of the drainage and cultivation which a former crowded population was enabled to pre- serve; and to the removal of those screens of trees which confined the exhalations to the place that generated them. The importance of these j considerations has been insisted on by Lancisi and Brocchi, in respect of Italy; by Monfal- I con, with reference to France; by Annesley and myself, in regard to warm climates; and by M'Culloch, as respects this country. It was ' remarked by Pliny, and some others, among the ancients, that trees absorb the exhalations which prove injurious to man; and the observation is perhaps just: but whether trees simply obstruct the transit of malaria from its source, and confine it there, or actually absorb it along with the mois- ture in the air, and dew which rests on their leaves; or whether they act in both ways, in ad- dition to their shading the soil from the action of the sun; the power they possess, in low and marshy situations, of moderating the generation of mala- ria, and confining it to its source, is indisputable. It is, therefore, important to plant trees around, : and more especially to leeward of, unhealthy places (§ 5.), in order to screen persons living in their immediate vicinity from their influence. Owing to the extent to which trees, high houses and walls, and intervening water not liable to i become stagnant, protect places near the sources ! of malaria from its effects, is to be explained the ' fact of the inhabitants of one side of a street, or road, often escaping ague, whilst many of those living on the other side are affected; and of the crew of one ship being seized with fever, while those of another, somewhat further removed from I the shore, escape. 23. C. There are other means, besides those ! enumerated, which both destroy and counteract, or otherwise remove, the causes of endemic mala- dies.—(a) In the case of impure water, filtering it, especially through charcoal; boiling it before it is used, or passing it through lime; preserving it in iron tanks on board ships; and adding to it a small quantity of either ofthe chlorurets, when it cannot be otherwise deprived of a portion of animal matter; are very important precautions. When sewers, drains, ditches, and other confined sources of impure air cannot be removed, or covered so as to prevent the emission of effluvia, the chloruret of lime should be thrown into them from time to time. A solution of the same sub- stance, or either of the other chlorurets, ought also to be liberally employed in the wards of ' crowded hospitals, whenever the air becomes close and foul, in order to prevent the prevalence of fever, dysentery, erysipelas, and gangrene ; and should also be poured down the privies. : Similar precautions ought also to be employed in crowded transports and ships of war, as well as in camps and besieged towns, more especially if dis- ease appears. But this means is only subsidiary to free ventilation; and is most to be confided in when the latter cannot be established. By having recourse to these disinfectants, the sickness that sometimes arises from the leakage of sugar, or the decomposition of vegetable matter collected 764 ENDEMIC DISEASES —Prevention of. in the hold or between the timbers of ships, and from the action of bilge watei on chips or shavings, as recorded by Sir W. Burnett and other able observers, and the ill effects contingent on the steeping of flax and hemp, may be entirely prevented. 24. (b) Whatever progress is made in civilis- ation, in the cultivation of the soil, and in the useful arts of life, tends to diminish the prevalence of endemic diseases. Improved modes of culture introduce a greater abundance of wholesome nourishment, and, together with a more extensive commerce, render subsistence much less pre- carious than in the ruder states of society. It is chiefly owing to these circumstances that scurvy, dysentery, and diseases ofthe skin, are much less common now than formerly. These, also, aided by personal and domestic cleanliness, much better clothing, and a freer ventilation of houses, hos- pitals, prisons, &c, have tended greatly to dimi- nish the general amount of mortality. As respects prisons, the diminution of disease, chiefly result- ing from stricter attention to cleanliness, ventila- tion, and diet, shown to have taken place in those of France, by M. Villerine, is most striking. At Lyons, from 1800 to 1806, the annual mor- j tality in the prisons was 1 in 19; from 1806 to j 1812, it was 1 in 31; from 1812 to 1819, it was 1 in 34; and from 1820 to 1826, 1 in 43. A similar amelioration has also been remarked in the prisons of Rouen, and some other large towns in that kingdom. Although other diseases may appear, there can be no doubt that those that are more strictly endemic diminish before the pro- gress of civilisation and the increase of the com- forts of life. 25. (c) The healthiness of the inhabitants de- pends much upon the choice of residence. This obtains, especially in warm climates, in respect of both casual and permanent residents. Where the winds blow from particular quarters, at certain seasons and hours of the day, buildings or en- campments should be placed so as to be, during the night especially, to windward ofthe principal sources of endemic disease. Ships, also, should be anchored, as much as possible, with a regard to this precaution, or at a distance from an un- healthy coast sufficiently great to admit of the dilution of the malaria, or of its absorption by the water, before the winds conveying it reach them. When a temporary residence must be to leeward of a swamp, then some advantage may accrue from lighting fires between it and this source of disease, particularly during night, and from double tents, within which gauze or fine net curtains are kept spread. Buildings either near, or to leeward of any source of malaria, or standing on a deep, moist, or argillaceous soil,. should be very high; the ground floor should be left unoccupied, and be open on every side to permit complete perflation; and that side ought to be always shut, on which the prevailing night or land winds blow, or towards the place from which unhealthy exhalations proceed. The in- habitants should also sleep near the tops of the houses, where, if built high, they will generally be placed above the more concentrated vapour and miasms, and, in great measure, beyond their influence; for, although gentle acclivities or hills in the vicinity will often attract malaria, or be I swept by currents of air conveying it, yet pre- I cipitous elevations and high houses, even near its sources, will frequently escape, as, from its spe- cific gravity, it is confined chiefly near the surface ofthe earth. 26. (d) The diet of persons exposed to noxious exhalations should be easy of digestion, and nou- rishing, but not heating. Animal food should be taken sparingly, and spirituous liquors and strong wines laid aside. The lighter and thinner wines may be used in moderation. In hot climates or seasons, exercise in the heat of the day, or while exposed to the sun's rays, ought to be avoided; but it should be regularly taken without causing fatigue. Such medicines as will promote the secretions and excretions, particularly those of the liver and bowels, may be resorted to when these functions require aid. For this purpose, two or three grains of blue pill, with the aloes and myrrh pill, may be taken at night, and equal parts ofthe compound infusions of gentian and senna in the morning. When exposure to malaria, either at night, or early in the morning, is to be dreaded, a moderate dose of bark or sulphate of quinine, with camphor or some warm spice, as Cayenne pepper, may be taken previously to such exposure. A fire should be lighted in the apartment, or near it; and care be taken to exclude the raw night air, especially in the direction of the sources of miasmata. On occasions of this kind, smoking cigars will be serviceable. The tenour of the mind should also be duly regulated. The de- pressing passions and ideas, and all undue excite- ment, as being liable to be followed by depres- sion, ought to be avoided. A calm, confident, and well-employed mind—moderately occupied, and interested with its pursuit, — unruffled by gusts of temper or passion—not weakened by inordinate indulgence ofthe desires — with a suf- ficient gratification of the wants and wishes to give a foretaste of more perfect enjoyment, and to leave still more to aspire after, so that the ca- pacity of gratification be not exhausted, — is that state which most successfully opposes the impres- sion of endemic influence, which, assisted by the sensual indulgences of some, the ill-regulated pas- sions and dispositions of others, and the careless- ness of many, prove so destructive to human life. BlBLIOG.AND REFER.—Hippocrates, De Afiribus, Aquis, et Locis, vol. i. p. 327. ; et De Sanitate tuenda, vol. i. p. 646. edit. Vander Linden.—Celsus, De Medicina, I. i.— J. Caius (J. Kaye), Boke or Conseil against the Disease called the Sweat, or Sweating Sicknesse, l2mo. Lond. 1552. —Andrew Borde, A Compendious Regiment or Dietary of Health made in Mount Pyllor (Montpellier), 1562.—F. Vander Mye, De Morbis Bredanis, Tempore Obsidionis, Ac. 4to. Antw. 1627.—J. Josselyn, Account of Two Voy. to New England, 12mo. Lond. 1674.—N. F. Domingo, De Morb. End. Sarag. 1686.—Claromontius, De Afire, Locis, et Aquis Terras Anglia-, deque Morbis Anglorum Vernaculis, 12mo. Lond. 1672.—Prosper Alpinus, lie Med. .Egypt, p. 49. et seq.—Stubner, De Nigrataruin Affectiooibus* Witt. 1699.—R. Towne, Of the Dis. most frequent in the Wet Indies, &.c. 8vo. Lond. 1726.—Lommius. in Celsum de San itate tuenda, 8vo. Leyd. 1724.—Cheyne, On Health and Long Life, 8vo. 1-734.-A/. M. Lancisi, De Noxiis Pallidum Effluviis, eorumque Kemediis, kc 4lo. Roma, 1716.—C. Wintringham, Treatise of Endemic Diseases, &c. Eb. 1718, Works, vol. i. p. l.—F. Hoffmann, De Morb. Certis Reg. et Populis Propiis. Halae, in Oper. vol. vi. p. 202.—Lohr, De Colica Flitulenta, Incolis Gedanensibus frequentissima. Erf. 1726.—Smith, De Colica apud Incolas Caribeenses Endem. Lugd. Bat. 1729.— Pohlius, De Morbo Endemio ah Aqua Irapura. Lips. 1749.—Subzer, De Morb. Helv tiia E d. Arg. 1740.—Mosca, Dell' Aria e dei Morbi. 4lo Nap. 1746 —Gaubius, De Regimine Mentis, 4to. Levd. 1747.— Sutton, On Extracting foul Air, kc 8vo. Lond. 17 9.— Hales, in Philos. Trans. 1755, p. 332.—Huxham, De Afire, EPHELIS — Lenticular. 765 8vo. Lond. 1752.; et in Philos. Trans. 1758, p. 528.—Lino!, On Preserving the Health of Seamen, 8vo. Lond. 1757.— Bisset On the Med. Const tution of Great Britain, 8vo. Lond. 1762.—J. Grainger, On (he more common West India Dis. Lond. 1754.—Fermin, Des Mai. les plus fiequeiltes a Suri- nam, 8vo. Amst. 1765.—Rutty, History of the Weather for Forty Years, 8vo. 1770.—Cartheuser, De Morbis Endemiis, 8vo. Fr. 1771.—Baty Morb. Hungaris Endem. et Remed. iisdem Familiar. Ultraj. 1775.—Hunter, On the Dis. ofthe Army in Jamaica, 8vo. Lond. 1796.—J. Millar, On the Prevailing Dis. of Great Britain, 8vo. Lond. 1775.—Rollo, On Preserving the Health in West Indies, 12mo. Lond. 1783.—Tournny, Variis Regionibus varii Morbi, &c. Nan- cei, 1783.—Don Ulloa, Mem. Phi os. sur l'Amerique, kc. Paris, 1737.—Haygarth, in Philos. Trans. m..—Rush, Med. Inquiries and Observations, vol. i. and ii. passim.—J. Gregory, DeCoeli Mutatione, 8vo. Ed. 1776.—Kirwan, On the Temperature of Diff. Latitudes, 8vo. Lond. 1787.— Finke, Medicinisch Pratische Geographie, 3 b. 8vo. Leips. 1792-5.—Fabricius, De Morb. End., in Doering, t. i. p. 88. —GmeHn, Reise durch Russland, vol. iii. p. 425.—Muller, De Caus. quare ingens Europ. Multitudo Bataviae pereal, et de Mali hujus Remediis. Goet. 1798.—Bunge, De Morbis Endemiis Ki.iviensibus. Jenae, 1798.—Formey Medicinische Topoeraphie von Berlin, 8vo. Ber. 1796.—C. Caldwell, On the Differences between the Endemic Dis. of the United States and those of Europe, kc I hil. 1802, 8vo.—Cassan, in Mem. de la Soc. Med. d'Emulation, an. 5. p. 56.—Rob- ertson, On the Atmosphere, 2 vols. 8vo.—Gai-nett, On the Preservation of Health, 12mo. Lond-. 181,0.—Guyton Mor- veau, Moyens de Desinfecter I'Air, 8vo. Par s. 1801.—Guy- ton et Chaptul, io Edin. Med. aud Surg. Journ. vol. ii. p. 290.—Gillespie, On the Preservation of the Health of Sea- men, 8vo. Lond. 1798.—R. Willan, Reporis on the Dis. of London from 1796 to 1800, 12mo. Lond. 1S01.—W. Heber- den, On the Increase and Decrease of Diseases, 4to. Lond. 1803. (Dysentery had greatly decreased; fever and rickets considerably; apoplexy, palsy, and consumption, hud in- creased, in London.)—Winterbottom, Med. Facts, vol. viii. p. 56.; and Directions for Hot Climates, l2mo. 1806.—bed- does, Manual of Health, l2mo. Lond. 1806.—Williams, On the Climate of Great Britain, and its Changes, 8vo. Lond. 1807.—Domeier, On Malta, 8vo. Lond. 1810.—Carter, On the Hospitals^ &c. of the Continent, 8vo. Lond. 1819.—J. Johnson, On the Influence of Civic Life, Sedentary Habits, &.c. 8vo. Lond. 1817.; on the Influence ofthe Atmosphere, &.c. Loud. 1818.; on the Influence of Tropical Climates on the Constilut. kc 4th ed. Lond. 1827. (Contains a large mass of information on endemic influence and diseas:.)— Mat- thews, Diary of an Invalid, 8vo. Lond. 1820.—G. Blane, in Trans, of Med. and Chirurg. Soc. of Lond. vol. iv. p. 89. 145.; and Select Dissertations, 2d edit. vol. i. p. 147. and 258.—A. Robertson, in Lond. Med. Repos. vol. i. p 367.— T. Bateman, Reporis ou the Dis. of London, and State of the Weather, fee. from 1804 lo 1816. Lond. 1819, 8vo.— J. Douglas, Medical Topography of Upper Canada, 8vo. Lond. 1819.—J. i op/and, Medical Tocography of the West Coast of Africa, in Journ. of For. Med. vol. ii. p. 1.—J. Devize, Tr ite de la Fievre Jaune, 8vo. Paris, 1820.—G. Brocchi, Considerazioni sull' Agro Romano Antico e sul Si o di Roma Antica, 4to. Rom. 1826.; et Del Stato Fisico de Suolo di Roma, 4to. Rom. 1820.—W. Ferguson, The Na- ture and History of Marsh Poison, Trans, of the Roy. Soc. of Edin. 1821.—H. Marshall, Med. Topography of Ceylon, &c. 8vo. Lond. 1822.—J. B. Monfalcon, Kistoire Medicale des Marais, kc. 8vo. Paris, 18^4.—Speer, On the Dis. of Lower Orders in Dublin, in Dub. Hosp. Rep. vol. iii. p. 161. —E. M. Builly, Trite Anatomico Pathologique des Fievre? Intermittentcs, kc 8vo. Paris, 1825.—J. Annesley, Bind Author, Researches into the I auses, Nature, and Treatment of Diseases of India and of Warm Climates, imp. 4to. vol. i. p. 47. et seq.—M. Dollemann, Disquisiliones Histor. de plerisque apu I Be gas Septentrionales Endemicis Morb. 4to. Amst. 1824.—J. Macculloch, On the Product, and Propaga- tion of Malaria, kc 8vo. Lond. 1827; and On Remittent and Intermittent Diseases, kc 2 vols. 8vo. Lond. 1828.— Rayer, in Archives Gen. de Mid. t. iv. p. 477., et t. v. p. 269. (Dis. of Paris.)—Fen-us, in Diet, de Med. t. viii. p. 66.—J. Hennen, Sketches of Med. Topography of Gibraltar, Ionian Islands, Malta, kc. 8vo. Lond. 1830.—H. Bellinaye, The Sources of Health and Disease in Communities, kc l2mo. Lond. 1831.—Andral, io Diet, de Mtd. et Chir. Prat. t. vii. p. 279. ENTERITIS. See Intestines — Inflamma- tion of. ENURESIS. See Urine—Incontinence of. EPHELIS. Syn. —'£(r,;/ic (from cii, and iAn.;. the sun). Macules Fuscte, Plenck. Epi- ehrosis Ephelis et Lenticula, Good. Ephelides, Alibert. Ephdlide, Fr. Spotted discolouration of the Skin. Classif.—10. Gen. 3. Order, 6. Class, (Good). 1. Gen. 8. Order, Macula (Bateman). I. Class, V. Order, (Author). 1. Defin .—Discolour ations ofthe skin, vary- ing from a yellowish grey to a dark Irown, and from minute points to large patches, and either scattered, confluent, or corymbose. 2. I. Forms and History.—Hippocrates applied the term ephelis to the freckles produced by the sun; but he also extended it to the spots sometimes seen in the faces of pregnant females. This extension of the term was adopted by Ori- basius, Ai'tius, Actuarius, and GorRjEus; and carried even much further by Plater, Sau- vages, and Alibert. Other words have been employed by modern writers, as a designation either for ephelis generically, or for certain of its varieties, as will be stated hereafter; but, as this appears to have been the original one, I shall adopt it here. The change of colour characterising it, is not seated in the cuticle, but in the pigmentum which gives the hue to the skin. It seems, in some instances, connected with a deficient tone of the extreme'vessels; and is very variable in its progress, occasionally coming on slowly, some- times rapidly and extensively. It is often of long duration, or even permanent; and in other cases it soon disappears, either spontaneously, or after the application of some lotion. In itself, it cannot be considered to require medical interfer- ence; but certain of its forms are important, as symptoms of internal disorder. It may be divi- ded into two species—the lenticular and diffused. i. Lenticular Ephelis. Syn.—Ephelis Len- ticularis; Lentigo, Lenticula, Auct. Lat.; Ephelis Lentigo, Sauvages and Todd; Lentigo Ephelis, Frank; Punnus lenticularis, Paget; Ephilide lentiforme, Alibert; Freckles. 3. This species is characterised by its fawn or brown colour, the spots being generally very small, and always under the size of a lentile, dissemi- nated, or in clusters; and without any elevation of the cuticle, or attendant irritation. Dr. Todd has veiy properly divided it into two varieties—viz. that which is congenital or dependent upon the complexion, and consequently sometimes heredi- tary ; and that which is caused by the sun. 4. A. Congenite Ephelis; uxo~-,Gr.; T&r.hes de Rousstur, Fr.; Ephelis Lentigo materna, Todd; Congenite Freckles.—This variety occurs most frequently in persons of a very fair com- plexion, with a delicate skin, and yellowish or reddish hair; and sometimes in those with a very white skin, and dark hair and eyes. The spots are lenticular, persistent, and not confined to the parts exposed to the light; but are in some cases dis- seminated over the body. They frequently do not become very apparent until some time after birth, or even not until the child is five or six years old. The darkness of the discolouration varies as above (§ 1.), with the colour of the hair or eyes, and usually remains till old age. 5. B. Solar lenticular Ephelis; Lenticula So- lar es; Macules Solares, Plenck; Ephelis a Sole, Sauvages; Lentigo ttstiva, J. Frank; Summer- ftecken, Sonnensprossen,Ger.; Evanescent Freck- les.—This is a common lenticular discolouration, occurring iu young persons, especially females, 766 EPHELIS — Diffused — Treatment. during spring and summer, and disappearing in winter; and limited to parts exposed to the sun. 1 hose who live in cities, or keep much within doors, are very liable to it when exposed to the sun and fresh air. The deepness ofthe discolour- ation generally varies with the colour of the hair; and the spots are most numerous in the face, par- ticularly of those who go bareheaded, or insuffi- ciently shaded from the sun's rays. u. Diffused Ephelis.—EphelisDiffusa,Todd. 6. This species is characterised by the irre- gular, diffused, and large patches, which vary more widely in colour than the foregoing species; and are sometimes distinct, sometimes confluent. It has been made to comprise certain discolour- ations, arising from various causes, and presenting very different appearances. Some of these pro- ceed from the direct action of heat and light, and others are symptomatic of an internal affection. 7. A. Idiopathic diffused Ephelis—Ephelis dif- fusa Idiopathica (Todd)—presents two very dis- tinct forms; that caused by the heat of fires, and that by the sun and air.—(a) The blotches pro- duced by artificial heat—Ephelis ignealis (Sau- vages), Ephelis spuria (J. P. Frank), Lenti- go ab Igne, (J. F-ra.uk),Taches de Briilure, Fr. —are generally seen on the legs, arms, and thighs of persons who sit near the fire, without any cov- ering intervening between these parts and it. They are usually of a mottled character, and often as- sume a livid, or purple, or purplish red, colour, especially when the surface is exposed to cold. They are met with chiefly in females.—(6) Sun- burn, or the diffused and general discolouration— Nigredo a Sole (Sennert), Fuscedo Cutis (Plenck), Ephelis umbrosa (J. Frank)—is merely the dark colour acquired by the skin after the protracted action of a high range of solar heat andatmospheric temperature,aided by the influence of the air, more especially sea air, and salt water. 8. B.- Symptomatic diffused Ephelis, Hepati- zon, Macula Hepatica (Sennert), Vitiligo Hepatica (Sauvages), Kelis fulvescens (Swf- diaur), Chloasma (the Franks), Ephelis dif- fusa Symptomatica (Todd), Pannus Hepaticus (Paget), Ephelides Hipatiques (Alibert), Taches Hepatiques (Fr.), Leberflecken (Germ.). This form of discolouration varies much in shade, and in the size of the patches. It is usually of a pale dirty yellow, or of a yellowish brown, or a light tawny shade; or it passes from a saffron to a rhubarb hue. The patches are occasionally pre- ceded by itching, are sometimes very slightly ele- vated, and then terminate in desquamation of the cuticle. They appear most frequently on the neck, over the regions ofthe liver and kidneys, on the groins, on the forehead, and sometimes about the mouth; and are generally distinct; but they usually run into each other as they extend, and often form groups or wide blotches. When slightly elevated, and followed by desquamation of the cuticle, they nearly approach the Pityria- sis versicolor of Bateman; and in this state are very dry and unperspirable, while the surrounding skin is soft and moist. They are either persist- ent, or of short duration, 'i he transient form of this discolouration is very common in delicate fe- males, particularly those whose uterine functions are disordered, and at the period of the catamenia. They occasionally appear suddenly, and disap- pear as speedily after a few hours; but they often remain a very considerable time, especially when they are connected with suppression of the menses (the Chloasma Amenorrhaum oi J. Frank), or with conception (the Ephelis Gravidarum of Plenck, and the Chloasma Gravidarum of Frank).—This form of ephelis is also sometimes connected with chronic disorders ofthe liver; but more frequently with those of the stomach and large bowels, and with those ofthe uterine organs. It is occasionally attendant upon haemorrhoids; and is very readily excited in those liable to it, by vexation and anxiety of mind. It is also very generally connected with a state of the digestive organs, characterised by a craving appetite, and imperfect digestion and assimilation. 9. II. Treatment.—The Lenticular Ephe- lis is frequently a matter of serious consideration to the fair sex; and ingenuity has been often tor- tured for means of removing it.—(a) In respect of the congenite variety (§4.), the remark of Celsus, as to the folly of those who attempt to remove it, is perfectly just.—(b) That variety, which is caused by the summer heat—the solar lenticular ephelis (§5.)—may be prevented by the use of veils and wide-brimmed hats; which will frequently assist its removal, when already produced. The articles—nostrums, cosmetics, &c.—which have been recommended for it, are beyond the possibility of enumeration ; every perfumer, &c. being possessed of a panacea. Gently astringent and discutient lotions and poultices have been most commonly employed. From the time of Hippocrates to the present, lotions and liniments with bitter almonds have been recommended. Celsus advised a liniment of resin with a little fossil salt and honey ; Actuarius, one with vinegar, honey, and bitter almonds; and Geoffrey, ox-gall, either alone, or with liquor potassa?. Dr. Thomson mentions a weak solution of corrosive sublimate in the emulsion of bitter almonds; and Dr. Bateman, a drachm of either sulphuric or muriatic acid, in half a pint of water, in the form of lotion. Dr. J.Frank prescribes the chloric acid in rose water (TT) xij.—xx. to 3 vj.); and Dr. Wither- ing, an infusion of horseradish in milk. Sour buttermilk is frequently employed in country places as a cosmetic wash. Besides these, a de- coction of powdered lupines, or tares, or of the narcissus root, or of the seeds of the garden cu- cumber; also poultices prepared from these, and from a great variety of roots; have been recom- mended. The balsam of Mecca, with super- acetate of lead, in the form of pomatum ; washes with the juice of sorrel, or with lime- juice and camphor mixture; also this last, with nitrate of potash, or with milk of sulphur, or with Venetian soap dissolved in lemon-juice; rubbing the parts with a slice of lemon or sour apple; so- lutions of zinci sulphas, in emollient vehicles ; and of the sub-borate of soda in rose water or orange-flower water (F. 334.); have also been employed, and frequently with success. Most of these are best applied at night, and washed off in the morning. 10. ii. The Diffused Ephelis, when proceeding directly from artificial or solar heat (§ 7.), dis- appears gradually upon the removal of the cause; and requires no further consideration. The symptomatic states are important only as symp- toms of internal disorder; and, as being generally EPIDEMICS —Causes, etc 767 connected with imperfect secretion, excretion,and assimilation, these functions should be assisted by mild, cooling, and alterative purgatives, light diet, and moderate exercise. Very small and frequent doses of blue pill or hydrarg. cum creta may be given with Castile soap and taraxacum, or with the aloes and myrrh pill, if the catame- nia are scanty; or with ox-gall, in addition. The internal use of the kreosote may also be tried. I have prescribed it, in one case of this kind, with great benefit. Sulphurous mineral waters may also be taken; and lotions with the sulphuret of potash, or with nitre and camphor julap ; or sul- phuretted fumigating baths resorted to. BIBLIOG. and REFER. — H ppocrates, Praenot. 1. ii. xxxi. 9.; De Alimento. iv. 18.; De Morb. Mulier. 1. ii. Ixvii. 6.—Celsus De Med. 1. vi. c. 5.—Aetius, Tetrabib. ii. ■er. iv. c. 11.—Oribasius, Synop. 1. viii. c. 33. ; De Loc. Afl'ect. Cur. 1. iv. c. 52. j e't De Virtute .^iinp. 1. ii. c. 1. (Bitter almonds.)—Avt'iarius, Meth. Med 1. iv. c. 13.— Sennertus, De Cutis V Ii s, 1. v. pars 3.—Gorraus, Defin. ad Vocem Eil'ij/.'n .— P!ater, De Superfic. Corp. Dolore, cap. 17.—Bender, De Cosmeticis. Arg. 8vo. 1764.—Lorry, De Morb. Cutaneis, Fit. Lentigo.—Sauvages, Nosol. Meth- od. CUss i. Gen. 3.-Plenck, De Morb. Cut. Class i. Sp. 2. —Alibert, Plate 26. and 27.—Bateman, Synopsis of Cut. Dis. bv A. T. Thomson, p. 441.—J. P. Frank, De Cur. Horn. Morbis, 1 iv. p. i 2. et seq.—J. Frank, Praxeos Me'd- icae Universal Praecepta, pars prima, vol. ii. p. 331. et 337.— Rayer, Traite Theor. et Prat, des Mai. de la Peau, t. ii. p. 206.; et Diet, de Mid. et Chir. Prat. t. vii. p. 369.—Caze- nare et Schedei, Abreee Prat, des Mai de la Peau 8vo. p. 370.—Todd, Cyclop, of Pract. Med. vol. ii. p. 69 —J. Pa- get, On the Classification of Diseases of the Skin, 8vo. p. 51. EPIDEMICS.—Epidemic Diseases; 'E.riih'jna, 'Eiidljioc, 'E.iidi',iuoc (from? W among, and dijioc, people). Epidemia, Epidemius, Epi- demicus, Morbi Epidemici, Morbi Publici, Morbi Populares, Auct. Lat. Epidemie, Fr. Volkskrankheit, Germ. Epidemia, Ital. Epi- demy, Epidemic Influence, Epidemic Constitu- tions. Classif.— General Pathology. 1. Epidemics are such diseases as occasion- ally prevail more or less generally in a commu- nity, at the same time or season, and depend upon a common cause.—They recur at uncertain periods; and continue to prevail for a time varying from two, three, or four months, to as many years, or even longer. When their spread is most ex- tensive, or throughout countries differently cir- cumstanced as to climate, &c, or when they are universal in their attack, they have often receiv- ed the appellation of Pandemic (7iaiSiluiog ornui Siiiuc, from .it'/-?, all, anddi'uo:, people). When, together with their very general prevalence, they occasion a very great mortality, they have usually been denominated pestilential (see art. Pf.sti- lf-nce). They are commonly acute and febrile, and often rapidly run their course. They appear at any season ofthe year; but most frequently in au- tumn, summer, and spring. They are distinguish- ed from endemic maladies by the circumstance of these latter being occasioned by peculiarity of sit- uation. But it should be recollected, that endem- ic diseases may be converted into epidemics of a very fatal kind, by those influences, either obvi- ous or inferred, to which attention will be direct- ed in this article ; and which, acting either sepa- rately or in combination, modify the character, whilst they cause the prevalence, of disease. 2. I. Causes, &c.—The Influences, whence epidemics proceed, may be traced in many in- stances; and in others, particularly those that are pestilential, they cannot be inferred with the same degree of probability. Certain epidemics have manifestly arisen out of combinations of circum- stances, the nature and operation of which admit not of dispute, whilst some have presented only certain elements of their causation, others being wanting to explain fully all the phenomena ob- served.— A. Amongst the most important ele- ments of epidemic influences, are those endemic sources which are amply described in the articles Climate (§3—32.); Disease — Causation of; and Endemic Influence (§ 5.). These sources often perform very important parts in the causation of epidemics, upon the addition of some other cause, either manifest or concealed; endemics being sometimes the parent stock upon which ep- idemics are engrafted : the latter varying in cha- racter with the nature of the superadded cause, or causes, especially those which are about to be noticed. Several of these additional causes may consist merely of certain changes from the usual course of the seasons, which obtain in these local- ities; as prolonged drought, or protracted rains; and still more, the former following the latter; and particularly if conjoined with increased tem- perature. As long as the temperature continues low, very material changes in the state of the seasons may not be productive of any increase of disease in unhealthy situations, unless other causes come into operation, as infection, deficient or un- wholesome food, &c. Hufeland states that, in IS 15 and 1816, in the north of Germany, the seasons were remarkably wet, and the tempera- ture low, and yet the public health was very good; that intermittents and low fevers were rare, even in marshy, localities; inflammations and rheumatism being the predominating maladies. In -warm countries, however, protracted and heavy rains generally occasion epidemic disease, especially in low and marshy places, during the subsequent hot or dry season, or when great num- bers of persons are crowded in a small space; and, moreover, impart to it an asthenic and in- fectious character. Of diseases originating in local sources, becoming infectious and epidemic, I could adduce several instances in modern times. Livy (1. xxv. 26.) states, that, during the siege of Syracuse by Marcellus, 213 years B. C, a pes- tilence broke out in both armies ; and that it oc- curred in autumn, and in a situation naturally un- healthy. " At first," he observes, " persons sickened and died, owing totheunwholesomeness of the place; afterwards the disease spread by infection, so that those who were seized were neglected, or abandoned, and died; or their atten- dants contracted the disease." He further adds, that the dead affected the sick, and the sick those in health, with terror and pestiferous stench; that the disease was more fatal to the Carthaginians than to the Romans, who, in this long siege, had become accustomed to the air and water; and that, in the same year, an epidemic visit- ed Rome and the adjoining country, which was remarkable rather for passing into chronic affec- tions, than for the mortality it occasioned. Al- though some of the sources of endemic disease may, by the aid of concurrent causes, as in the instance now quoted, give rise to epidemics, yet pestilential epidemics otherwise originating, as in infection, have sometimes spared places which have seemed to abound the most in certain causes of insalubrity; but this has occurred only when 768 EPIDEMICS —Causes, etc. those places have emitted a powerful stench, u- a"imomacal vapours, or other strong odours, which have either counteracted, or neutralised, the exhalations or miasms which have spread the infection. 3. B. The seasons have a very remarkable in- fluence upon certain epidemics, as those of yellow fever and plague; and but little on others, as pesti- lential cholera, influenza, &c. As respects those epidemics which are less universal and fatal, the influence of the seasons is more or less manifest. — In spring, various forms of angina, croup, bron- ration and diffusion. On this point I cannot agree with Dr. Hancock, M. Foderf, and some other modern authors. That this dictum ol Hippo- crates was not altogether believed, even in ancient times, may be inferred from the frequent excep- tions to it adduced by historians and medical witers. Tacitus (Annalium, 1. xvi. 13.), when noticing the epidemic that raged at Rome in the year 68, states, that there was no irregularity of season, or weather, to account for it. The plague that prevailed so long, and spread so gen- erally, between the middle and end of the sixth chial affections, inflammations of the lungs and century, and which has been fully described by pleura, catarrhs, rheumatism, hooping cough, ter tian or quotidian agues, and the febrile exanthema- ta, as measles, &c, are usually most prevalent. — In summer, certain of the above diseases will often remain, with continued fevers of various forms, erysipelas, smallpox, stomach and bowel com- plaints, &c.— In autumn, the diseases of summer either continue, or become more prevalent, espe- cially cholera, dysentery, and colicky affections; and quartan or irregular agues, remittents, sore throat, scarlatina, inflammations, or obstructions ofthe abdominial viscera, &c. are also frequent. — In winter, inflammations of the thoracic and respiratory organs, rheumatism, and low or ty- phoid fevers, are most common; and in close or crowded places, infectious effluvia, either from the sick or from accumulated filth, are readily gene- rated, when the air in heated apartments becomes stagnant. Hippocrates had remarked that, when the seasons are regular,diseases are also more regular in their course; and, unless during the prev- alence of epidemics, the observation appears just. 4. C. The weather has a considerable influence on the prevalence of the more common diseases. Protracted droughts are unfavourable to pulmo- nary diseases, with the exception of bronchor- rhoea, and frequently excite inflammations and in- flammatory fevers. During, and soon after, very wet seasons, gastric, remittent and intermittent fevers, catarrhal and rheumatic affections, dys- entery, diarrhoea, and sore throat, are often epi- demic. The frequent recurrence, or the continu- ance, of high and cold winds, occasion catarrhal, pectoral, inflammatory, and rheumatic diseases; and warm or hot winds induce remittent and bil- ious fevers, cholera, ophthalmia, &c. Calm humid states ofthe air promote the spread of continued Procopius and Evagrius, who were witnesses of it, was in no way dependent upon irregularity of season, but was evidently propagated by in- fection. The following remarks of Evagrius are, according to the experience of every candid observer, perfectly characteristic of an infectious pestilential epidemic : — "Some perished by once entering into, or remaining in, the infected houses; some, by touching the sick. Some contracted the disease in open market: others, who fled from infected places, remained safe; while they com- municated the disease to others, who died. .Many who remained with the sick, and freely handled the dead bodies, did not contract the disease." (Eccles. Hist. 1. iv. cap. 29.) The pestilence called the Black Death, which visited nearly all the then known world in 1347, 134S, 1349, and 1350, was equally independent of irregularity of season, or deficiency of food. Parker (Antiq. Brit. p. 360.) states, that it first appeared in the south of England, about Christinas, 134S, and amidst the greatest abundance of provisions. Thuanus and Riverius, when noticing the epidemic that broke out in France in 1580, re- marked, that the crops that year were plentiful, and the sky serene; so that it was thought that the disease was produced rather by the influence of the stars than by the malignity of a corrupt air. Webster (On Epidemic Diseases, vol. i. p. 323.) admits, that the summer in 1665, in England, when the plague commenced in Lon- don, was very temperate, the weather fine, and the fruits good. All the writers ofthe day agree that no cause of pestilence could be observed in the states of the seasons. The epidemics of our own days also prove that, although irregularities of seasons and weather, particularly in the en- fevers, and all infectious and contagious maladies; demic sources of disease, may aid in. the diffusion and similar conditions of the atmosphere, con- of pestilential maladies, or give rise to increased joined with great heat, favour the prevalence of prevalence of the common diseases, they are by adynamic and malignant fevers of a continued or (no means amongst the chief causes ofthe former, remittent type; whilst very hot and dry seasons give rise to synochal and ardent fevers, to bilious remittents, cholera, and inflammations ofthe liver, stomach and bowels. 5. Although the states of the atmosphere here 6. D. In connection with, and often resulting from, irregularity and inclemency of seasons, un- wholesome and deficient food sometimes performs an important part in the production of epidemics, — a fact which seems to have been well known enumerated, very frequently produce the effects ! and guarded against by the inspired lawgiver, Mo ascribed to them respectively, yet other causes aid their operation. Writers, from Hippocrates downwards, have attributed too much to irregular- ities and sudden vicissitudes of season in the pro- ses. In Deuteronomy (ch. xxviii), the Israelites are warned against transgressing his laws ; and are threatened, as a consequence of disobedience, with the diseases of Egypt — the botch, the scab, duction of epidemics, more especially of those ! and the emerods; maladies known at present, by which are very general or pestilential. I believe that this cause is instrumental chiefly in augment- ing the number of cases ofthe diseases common the names of elephantiasis, leprosy, and plague, respectively, to prevail in that country; and in Numbers (ch. xi.), they are stated to have been to a country; and that it is very seldom the only, seized by pestilence from eating a great quantity of or even the chief, source of wide-spreading or pes- j the flesh of quails, which had fallen in surprising tilential maladies, althongh it may aid their gene- numbers around their camp, after having been EPIDEMICS—Causes, etc 769 long destitute of animal food,— a consequence of the circumstances in which they were placed, and of the unwholesome nature of their food. Fodere states that, during 1815,1816, and 1817, in several parts of Italy and France, the inhabit- ants were obliged to have recourse to such roots and herbs as they could procure, the grain having been remarkably scarce and of bad quality; and that, in consequence, scurvy, diseases of the skin, and malignant and infectious fevers, became very prevalent among the lower classes. A simi- lar circumstance was observed at Marseilles in 1812 and 1813 ; and in Ireland, on several occa- sions since the commencement of the present century; typhoid and low fevers, and dysentery, being the most prevalent results. Diseased or unripe grain, or alterations which it may have .undergone in granaries, and the admixture of seeds which are injurious with it, are also very influential agents of disease. In years of scar- city, both grain and roots are often prepared for food before they have acquired due maturity; and in that state derange not merely the alimentary canal, but also the nervous and circulating sys- tems, at a period when want and debility have rendered them more than usually susceptible of disorder. Malignant fevers, dysentery, convul- sive affections, scurvy, ergotism, raphania, &c. have, in numerous instances, proceeded chiefly from diseased or altered grain. M. Fodere mentions, in addition fo the more specific effects of ergoted rye (see Ergotism), its causing abor- tions to become epidemic. 7. (b) Flesh of animals, and fish, when dis- eased, or tainted, are not infrequently produc- tive of most dangerous maladies. Epidemics often commence among the lower animals; espe- cially horned cattle and sheep; and the use of the diseased flesh may occasion malignant diseases among the human species. Whether or not in- fection may be conveyed from these animals whilst alive, to man, during epizooties, has not been ascertained, nor, indeed, has the question been fully entertained. That it can be thus conveyed in respect of some maladies, has been proved in modern times. Fodere adduces a very con- vincing proof of the ill effects of diseased flesh in the production of dysentery and typhoid or ady- namic fevers. At a period when the French troops, in the late war, were in want of provi- sions, over-driven cattle, some of them diseased chiefly from this circumstance, were killed before time was allowed them to recover their fatigue. Their flesh was remarkably red, and passed quickly into decomposition. Most of those who partook of it were seized with febrile and malig- nant dysentery. During the French war in Prus- sia, Germany, and Italy, the sound meat and grain were often carried off by the victorious armies, leaving the unhealthy animals, &c. to the inhabitants, who became, from the nature of their food, the prey of epidemic fever and dysentery. The blood and viscera of these animals are generally most noxious, from being especially affected ; and it is fully established that these parts become principally diseased in the persons who are seized by these maladies from this cause. The muscular flesh of cattle attacked by an epizooty much sooner presents ap- pearances of alteration after death, than that be- longing to such as are healthy. It cannot, there- fore, fail of being productive of disease in those who partake of it, notwithstanding the effect of cookery in counteracting its noxious tendency. 8. (c) The agency of unripe, stale, or other- wise unwholesome fruit, and of stale and diseased fish of any kind, in the production of certain epidemics, is fully shown in the article Disease (§46.), and in the sequel.—(d) The operation of unwholesome water, although especially ma- nifested in the causation of endemic distempers, is also productive of those that are epidemic, par- ticularly on occasions of inundation of the sea ; as observed on several occasions in Holland, Italy, and many places within the tropics.—(e) M. Fodere states, that during a tour lately made in the Low Countries and French Flanders, he learnt that functional and organic affections of the stomach were sometimes epidemic there, from the use of spiced spirits and cordials, and the practice of adding lime and alkaline substances to the beer to prevent it from becoming acid. The well-known exclamation which Shakspeare puts in the mouth of Falstaff would lead to the inference that lime was very generally used, in the sixteenth century, to remove or prevent acidity in the white wines then drunk. This, however, is a cause rather of endemic than of epidemic diseases. The ill effects of adding delet- erious narcotics to beer—even to the small-beer— in this country, although satisfactorily shown in the production of a great variety of disorders, chiefly of the digestive organs and nervous systems, seldom manifest themselves in a form so specific as to be recognised as epidemic or even endemic. 9. E. a. Several writers on the epidemic appear- ance of certain diseases, finding that neither of the foregoing description of causes could account for them, have had recourse to various supposi- titious agents, of the nature of which they are entirely ignorant, and even the existence of which they have not been able to demonstrate. These agents have been supposed by some to be a mal- aria or principle of a peculiar kind, generated by the prolonged action of the sun, or by heat, upon low absorbent soils, and exerting a very noxious operation on the human constitution; and by others, to be a peculiar aura, or fluid, which has escaped from more deep-seated parts of the earth ; and, although altogether incognizable to the senses, yet most destructive to human life. The former opinion is maintained by many, es- pecially by Jackson, Ferguson, Deveze, O'Hali.oran, Dickson, Robertson, &c; the latter, also, by a numerous body of physicians. Noah Webster endeavoured by most laborious research to connect the appearance of epidemics with volcanoes, earthquakes, and comets,— sup- posing that they all depend upon the same cause, or that the changes produced by the latter give rise to the former, either directly by their action on the human frame, or indirectly by blighting the productions ofthe earth, and thereby deteriorating the chief articles of food. In struggling through a dry and meagre enumeration of epidemics—slight as well as pestilential — furnished by this writer, the reader is often amused by the attempts to con- nect an influenza, or some other epidemic, in Eu- rope, with an earthquake in America or in Asia, or with a comet that had appeared two or three years either previously or subsequently, or with some such phenomenon, as the fall of meteoric stones. 770 EPIDEMICS —Causes, etc 10. 6. Other authors have ascribed an unusual I Such occurrences are as old as the records of his- prevalence of disease, or the appearance of pes- tory extend; and have been adverted to in the Books tilential epidemics, chiefly to the states of elec- tricity in the air, and on the earth's surface. That certain conditions of this agent should affect the animal economy, and either predispose it to be infected by the exciting causes, or of itself be a principal cause, of disease, is probable ; but we have no direct proof of any connection between epidemics and known changes in the electrical states, either of the air, or of objects on the earth's surface ; and even granting that such connection exists, there is no evidence that this agent can produce the morbid effects ascribed to it. It is impossible to reconcile the modes in which epidemics are observed to diffuse themselves, or the peculiar and novel characters they often as- sume, or the very opposite physical circumstances in which they occur, merely with changes in the electric fluids, often of inappreciable and insen- sible kinds. Indeed, experience rather shows that the body may be made the medium of a very energetic electrical, or electro-motive, action, without any injury being inflicted on it; and it is only when a very powerful and very manifest current of either the negative or positive electri- cities strikes, or passes through it, that life is thereby in any way affected. 1L c. Numerous instances have occurred of the lower animals participating in the fatal effects of an epidemic constitution, and they have been adduced by modern authors as proofs of the existence of a noxious effluvium in the air, however it may have been generated. Thus it has been observed, that epizooties have preceded the prevalence of fevers; that catarrhal affections in horses have been fol- lowed by influenza; that birds have either for- saken the vicinity of a town ravaged by a pesti- lence, or have fallen dead when flying over it; and that numerous species of animals, particu- larly domestic animals, have died in houses visited by pestilential maladies. These pheno- mena have been adduced as proofs of the exist- ence of some one of the agencies placed under this head. Without disputing their actual oc- currence, or attempting to reduce them to their exact dimensions, from which they had been ex- aggerated for the purposes of argument, I will receive them as they have been described by those who have adduced them in support of their views. —1st. As respects epizooties in connection with epidemic fevers, Lancisi, Ramazzini, and still more modern writers, have furnished much in- formation. It has very frequently been observed, when the prevailing fevers have been an ex- aggerated form of the endemic of the country, or when endemic sources have been manifestly concerned in their causation, that the lower ani- mals, especially horned cattle and sheep, which derive their sustenance chiefly in places produc- tive of malaria, are the first to experience its effects, when it is more than usually active or concentrated. This is nothing more than what might be inferred a priori. We know that remittent and continued fevers, in various forms, are frequently epidemic, especially in marshy countries in the south of Europe ; are chiefly dependent upon local sources, aided by heat, crowding, imperfect ventilation, neglect of cleanliness, and the state of society; and are often either preceded or accompanied by epizooties. of Moses, as well as in those of the Prophets. Homer has signalised the connection, and Eus- tathius and Spondanus have explained it, in their commentaries on the Iliad, as satisfactorily as any philosopher of the present day. Eusta- thius, the celebrated critic ofthe twelfth cen- tury, ascribes the disease that broke out in the Grecian camp, in the tenth year of the siege of Troy, to immoderate heat and gross exhalations: and Dr. Sponde, or Spondanus, as he is com- monly called, conceived the circumstance of the mules and dogs having been affected before man, to have been owing to their natural quickness of smell, rendering the exhalations sooner perceivable and operative ; and to their feeding on the earth with prone heads, whereby effluvia are more readily inhaled, and before they rise so as to affect man, or become diffused in the air. 12. A connection similar to the above, and evidently proceeding from the same sources, es- pecially in warm or dry seasons, consequent upon the inundations of low grounds or marshes, is mentioned in various places by Livy. Tliat the epidemics, which were thus consequent upon or attended by epizooties, were ofthe nature I have contended for, may be inferred from the following notice he has recorded of an epidemic fever which was remarkably destructive in the year of Rome 576 :— " Pestilentia, quoe priore anno in boves ingruerat, eo verterat in hominum morbos. Qui inciderant haud facile septimum diem superabant: qui superaverant longinquo, maxime quartans implicabantur morbo. Servilia maxime morie- bantur ; eorum strages per omnes vias insepul- torum erat. Ne liberorum quidem funeribus Libitina subficiebat. Cadavera intacta a canibus ac vulturibus, tabes absumebat; satisque con- stabat nee illo, nee priore anno, in tanta strage boum, horninumque, vulturium usquam visum." (L. xii. 21.) Here the commencement of the disease amongst the cattle, its subsidence into the intermittent type, its greater prevalence in the lowest classes, and the absence of birds of prey from the infected atmosphere, are proofs — 1st, of its having originated in malaria, and pos- sessed the characters distinguishing this class of fevers; and, 2d, of the effect ofthe contaminated air and diseased bodies on animals of prey. The destructive epidemic that ravaged Rome in the year A. D. 187, and many parts of Italy, was attended, rather than preceded, by a disease in cattle. Herodia.n (L. i.) ascribes it to the great concourse of people assembled from all parts of the earth, and to an unfruitful year, and consequent famine,— causes most likely to generate infection, particularly when aided by others which are sel- dom absent under such circumstances. Although this connection of epizooties and epidemics may be explained as was attempted by Ecstathius and Spondanus, yet it is not improbable, that cattle confined together in a state of disease will generate an effluvium, remarkably injurious to man; that the use of the flesh of diseased ani- mals, as may be inferred to have been the case in the epidemic last noticed, will have a similar effect; and that, when aided by other noxious agents, both these causes will occasion an in- fectious malady, which will spread with great rapidity and mortality under the circumstances EPIDEMICS —Causes, etc. 771 in which these epidemics were observed. The facts already adduced (§7.), support this infer- ence; the following further tend to confirm it :— Livy, Dionysius of Halicarnassus, and Oro- sius mention a destructive pestilence which Rome and its territory experienced 464 years B. C. It seems to have occurred in autumn, and to have arisen from the crowds of countrymen and herds of cattle received within the walls of the city. " Ea colluvio," Livy remarks, " mixto- rum omnis generis animantium, et odore insolito urbanos, et agrestem, confertum in arcta tecta, sestu ac vigiliis angebat, ministeriaque in vicem ac contagio ipsa vulgabant morbos " (L. iii. 6.) The circumstance here so very explicitly stated, the vicinity of the Pontine marshes, and the state of the surrounding country admitting of inundations from any unusual rise of the Tyber, fully explain the occurrence of this epidemic. About ten years afterwards, another epidemic ravaged Rome, and was connected with famine and disease among cattle. In the year of this city 325, or twenty- five years subsequently, a remarkable drought and famine visited the Roman territory, the springs of water even having been dried up. Livy states, that " multitudes of cattle thronged round the arid fountains, and perished with thirst. Diseases followed, first invading cattle, and infecting the rustics and the lower classes of people, and then extending to the city." (L. iv. 30.) Dr. Hodges states, that the plague of London in 1665 was preceded by sickness among cattle, and that bad meat was consequently sold to the poor so cheap that they fed upon it to excess,—a circumstance that could not fail of predisposing them to be affected by its principal causes.—During the epi- demic of New Orleans in 1819, cattle, sheep, and horses were affected, evidently owing to the concentrated malaria concerned in causing the disease. 13. 2d. It has been supposed that the death or absence of birds during an epidemic is evidence of the dependence of such epidemic upon terres- trial exhalations. But it should first be ascer- tained at what period this phenomenon occurs; for if it precede the disease in the human species, then it may be inferred that these exhalations are concerned more or less in causing that disease. But if it take place during the course of the epi- demic, then it may arise from the infection of the atmosphere by the exhalations from the sick; the feathered creation, owing to the extent of their respiratory organs, and to their relatively large consumption of air, being very susceptible to changes in this fluid. I believe that the pheno- menon in question has occurred only during pes- tilential epidemics, where the sickness and mor- tality have been very great; and that it has pro- ceeded from this latter cause. This is proved by the circumstances in which it has been observed. Thucydides states, that, during the plague of Athens, birds that prey on human flesh entirely disappeared. Analogous facts were noticed by Diemerbroeck during the plague of Nimeguen; by Sir J. Fellowes, during the epidemic of Cadiz; and at Dantzic in 1709, according to Short. It has likewise been remarked that do- mestic animals have died, during these epidemics, similarly affected to man. In these cases, the infection has manifestly extended from the latter to the former; the air having been contaminated by the effluvium exhaled from the sick.* 14. F. The putrefaction of animal substances has been supposed by many to occasion disease in those who come within the sphere of the ex- halations thus produced, and even to generate a malady which has become infectious, and has, partly thereby, and partly from other concurring causes, prevailed to an epidemic, or even pesti- lential, extent. It is not, however, merely dead animal bodies, or considerable collections of pu- trid matter, but also heaps of filth exposed in the streets, or animal excretions and exuviae, subject- ed to a warm and stagnant air, and neglect of do- mestic and personal cleanliness, that are thus in- jurious. These latter may be less energetic agents than the foregoing; but they more frequently exist, and are more common concurrent causes. The injurious effects, however, of putrefying ani- mal substances have been denied by Dr. Ban- croft and others, by a species of argumentation more specious than solid—by a kind of medical special pleading, of which we have had more, since the commencement of this century, than is consistent either with facts or with the advan- ced state of general science. Animal substan- ces in a state of decay will produce effects, vary- ing with the temperature and humidity of the air, with the concentration of the exhalations proceeding therefrom, and with the state of in- dividuals, or of the community, exposed to them. A candid appreciation of the facts which have occurred to most experienced observers, in con- nection with those recorded by creditable writers, will, I believe, warrant the following inferences; — 1st. That in low ranges of temperature, the emanations from putrid animal substances will seldom be productive of marked effects, unless they accumulate or become concentrated in a stagnant atmosphere — unless they be assisted by * Th, I seize, I attack). MorbusSacer, Hippocrates. Morbus Major, Celsus. Mor- bus Herculeus, Aristotle. Morbus Comitialis, Pliny et Seneca. Morbus Convivalis, Plau- tus. Morbus Lunaticus, Aretaeus. Analepsia, Riverius. Apoplexia parva; Caduca Passio; Morbus Sonticus, Caducus, Astralis, Sidera- tus, Scelestus, Dcemoniacus, Deificus, Divinus, Sancti Johannis, fcedus, puerilis, insputatus; Pedilio; Epileptica Passio; Cataptosis, var. Auct. Lat. Epilepsie, Mal-Caduc, Mai de St. Jean, Fr. Fallsucht, Die Fallende Sucht, Germ. Mai Caduco, Ital. Falling Sickness, fiits itself to the practitioner and not 66* as it is usually described by systematic writers, who have viewed it (and, indeed, all other dis- eases) as a distinct species, and not as it com- monly occurs — as a concatenation or group of morbid phenomena, which varies infinitely in form, intensity, and combination, and consequently ap- proximates more or less nearly to other morbid actions, particularly of the same system or organ, and which may either pass into them, or appear in their course. 3. I. Description, &c. — In order to enter- tain satisfactory ideas of the nature and morbid relations of epilepsy, it should be studied as to — 1st, the phenomena which precede its evolution; 2dly, the signs indicating the approach of the par- oxysm; 3dly, the paroxysm itself, and the phe- nomena immediately consequent upon it; and, 4thly, the intervals between the seizures. M. Andral has adopted a nearly similar arrange- ment, which, however, is merely a modification of that of J. Frank, the latter, upon the whole, being the preferable of the two. Having describ- ed the more ratrular states of the malady, I shall take a brief view of its varieties and complica- tions. 4. A. The phenomena preceding the evolution ofthe disease.—J. Frank remarks that, of three hundred cases, the early history of which he had the opportunity of investigating, very few occur- red in persons who had been perfectly healthy previously to the accession of the disease. This, however, had notescapedRivERius and Tissot, the latter of whom has treated specifically "On the Diseases which precede Epilepsy." This malady attacks chiefly those persons who had been subject to convulsions during their first den- tition; to tinea capitis, or other chronic eruptions in early life; to diseases of the head, violent af- fections of temper, or to disorders of mind; to an unbridled indulgence of the passions; to diseases of the ear; to affections of the glandular and lymphatic system; to worms, to chorea, or to hysteria, at any period previously to the epilep- tic seizure. Many of these antecedent disorders may be viewed either as predisposing or exciting causes; or as indications of those early disturban- ces of the nervous systems, and of the circulation of the cerebro-spinal centres, that lead on to fur- ther changes, when left to themselves, until the fully formed epileptic seizure is the result. Thus, it is not infrequently remarked that epileptic pa- tients have, long before the accession of the disease, complained of tremors, cramps, vertigo, partial paralysis, disorders of sensation, chorea, stammering, palpitations, epistaxis, &c; or have received injuries on the head. The relations of these with the seizure, as well as of those noticed above, must be obvious to all. There are also other disorders which precede the disease; but which, being more intimately related to its caus- es, will be noticed hereafter. 5. B. Phenomena premonitory of the seizure. —As this disease rarely attacks a sound consti- tution, or person previously in good health, so each paroxysm frequently is preceded by some indication or other of its approach. Instances, however, are common, of persons being seized without any intimation, and even in the day- time, as suddenly as if struck by lightning. Wed el, Hf.nke, and J. Frank refer to seve- ral such. The last writer thinks it a rare occur- 786 EPILEPSY—Description of. rence; but I agree with Eso.uirol, in consider- ing it by no means uncommon, particularly in the idiopathic form; the symptomatic form being generally preceded by some indication. In two cases at present under my care, the seizures are instantaneous and unexpected: and I have met with several such, chiefly in those idiopathically affected, or who have inherited the disease. 6. The premonitory signs of the fit are, gene- rally, increased sensibility, or a sense of formi- cation of the surface, or of some particular part, as the arm, back, breast, &c; cramps; turgidity ofthe vessels ofthe head; redness of the counte- nance; a peculiar, anxious, or fixed look; heavi- ness or obtuse pain of the head; vertigo, or par- ticular sensibility, or a feeling of emptiness or coldness in the head; a great paleness ofthe face, and paleness or blueness of the lips and gums; a deeper sleep than usual; sleeplessness, or sleep attended by startings or peculiar succussions of various parts of the body, or disturbed by singu- lar dreams and visions, or by the nightmare; a sensation of sinking, or leipothymia, when falling asleep; unusual states of temper; irritability, or marked disposition to anger; various hallucina- tions, or spectral illusions ; great timidity, or unusual depression or serenity of mind; anxious deportment; great hilarity or mental excitation : an uncommon feeling of strength, or of robust health; sudden loss of recollection, confusion of ideas, or forgetfulness; unsteady gait; a desire of motion, or an irresistible impulse to run forwards; shivering of the limbs; dimness of sight; red or black objects, or coruscations or scintillations, be- fore the eyes; trembling of the iris, or alternate contractions and dilatations of the pupils; tempo- rary loss of sight, double or partial vision, or strabismus; a rush of tears; deafness, or a sense of humming, roaring, or other noises in the ears; a morbid perception of colours, of odours, or of flavours; a sense of sweetness in the mouth; a flow of saliva; violent sneezing, hiccup, frequent yawning, attended by a feeling of anxiety at the praecordia ; pandiculation ; difficulty of articula- tion, or stammering ; distortion of the counte- nance; spasmodic affections of the larynx; faint- ing, or leipothymia; palpitations; borborygmi; a sense of constriction in the fauces, throat, thorax, or abdomen ; cramps in the stomach ; great voracity, or unusual craving of the appe- tite; a copious discharge of watery or offensive urine, or haematuria ; a peculiar fcetor of the faeces; more frequently eructations, nausea, and vomiting, or other dyspeptic symptoms; and still more commonly the aura epileptica. J. Frank saw the paroxysm preceded by an eruption, over the whole body, excepting the face, of the vitiligo alba. He states, that in twenty-one epileptics treated in the clinical wards of the hospital at Wilna, vomiting announced the paroxysm in seven. 7. More than two or three of the foregoing symptoms seldom exist at the same time; but they sometimes precede one another. Thus, in a case which I lately attended, the patient was unusually excited in the morning, was restless, could not sit in one place any time, and desired me not to call again, as he never felt better in health and spirits than he did at that time. As 1 had been seeing him from time to time, on account of an indifferent state of health, I requested his friends to watch him. In the afternoon, he turned pale, felt very cold, complained of pain in one eye-ball, became sick, vomited, and instantly was severely seized. Another patient felt an unusual craving for food, with faintness, sunk and pallid features, most distressing sense of sinking, fol- lowed by violent palpitations; and directly after- wards, experienced a severe paroxysm; the pulse becoming irregular and intermitting during its con- tinuance. The sensation of a cold or warm aura proceeding from some part, and ascending to the head, but very rarely descending from the head to another part, is one of the most common pre- cursors of the fit. In some cases, the aura has been felt to terminate at the epigastrium. The places whence it most frequently proceeds are, various parts of the upper and lower extremities, the groins, hypochondria, abdomen, loins, uterine regions or vulva, along the vertebral column, and from the vertex to the occiput. Fernf.lius mentions its occurrence at the vertex; and Schf- lhammer, a case in which it commenced at this part, and proceeded to the arm. From whatever place the aura may arise, as soon as it reaches the head, or ceases, the patient loses all conscious- ness, and the fit is fully declared. 8. C. Phenomena characterising and directly following the fit.—It is only during the paroxysm that the characterised symptoms are observed. These may be so violent as to appear most fright- ful, or so slight or momentary as to be hardly observed, with every intermediate grade. This has led to the arbitrary distinction adopted by EsquiROL, Foville, Calmiel, and Andral, into the Grand and Petit Mai. The former, or fully developed paroxysm, may be divided into three stages.—(a) In the first, or that oi tetanic rigidity, the patient, either without any premo- nition, or after having felt one or more of the precursory signs above enumerated, generally ut- ters a scream or exclamation, of which he has no recollection afterwards, and instantly falls back- wards, if standing. Sometimes he runs some steps forward, or turns so as to describe a semi- circle or circle, and then falls to the ground. Rarely he turns rapidly around more than once, as remarked by Kriegal, Wedel, Bang, Valentin, Lobenstein-Lobel, Esquirol, and J. Frank ; or is thrown into a sort of danc- ing motion,—a circumstance which led Fabri- cius to describe a variety of the disease by the name of Epilepsia Saltator. Directly afterwards the whole body assumes an almost tetanic stiff- ness; the head is drawn backwards; the eyes are generally open, and directed from the usual axis of vision; the limbs are thrown out forcibly, and become rigid; and the muscles of the thorax and abdomen firmly contracted. The pulse is either irregular, or natural, or slower than usual. The face is very pale, unless cerebral congestion pre- cede the attack; and the respiration is impeded by the spastic contraction of the thoracic muscles. Occasionally, one half of the body is more affect- ed than the other; and erection generally occurs in the male, with retraction of the testes. This stage is usually of very short duration, passing in some seconds, or almost instantaneously, into the next. 9. (b) In the second stage, or that of convul- sion, the phenomena differ in no respect from those characterising the tonic form of Con vulsiok EPILEPSY—Description of. 787 (§ 12.), excepting in the more profound insensi- I bility attending it, which is so great that the patient may be subjected to the most painful applications without sensation being excited. The whole body is generally thrown into the most violent convulsions, so that, as Aretjeus has remarked, the spectators dread the imme- diate extinction of life. The head is violently rotated, or tossed in every direction ; the vessels of the head and neck are enormously swollen ; the eye-brows, forehead, and scalp are much agitated or contracted ; the hair is erect; the eyelids are either open, half shut, or convulsed ; the eyes fixed, prominent, vacant, rolled about, or turned upwards, or out of their axis ;. and the pupils are either dilated, contracted, or natural ; bat the motions of the iris are very slow, or en- tirely abolished. This varying state of the pupils accounts for the different descriptions given by Henke, Sprengil, Mjctzgf.r, Schmid- tmuller, Schmalz, Dressig, and others. The face, which was generally at first pale, now becomes injected, tumid, and livid ; the forehead contracted and wrinkled; the lips are at one time contracted, elongated, and pushed forwards, and at another drawn forcibly backwards ; the teeth are gnashed ; and the jaws so forcibly moved as to produce a remarkable stridor, or even to break the teeth. Van Swieten saw dislocation ofthe jaws owing to their violent action. The tongue is generally swollen, livid, forcibly protruded between the teeth, and more or less injured in consequence. The arms are tossed about vio- lently or struck against the chest; and the hands and fingers rapidly perform the motions of flexion, extension, &c. The lower extremities are simi- larly convulsed. The thumbs are drawn in- wards, and the toes incurvated. The convulsions are often more violent on one side than another. In some cases, much fulness of the abdomen and hypochondria is observed, often with borborygmi or singultus. 10. Respiration, which was at first interrupted by the spasm of the thoracic muscles, and per- formed as if the chest were placed under a load, or as in the act of strangulation or suffocation, until a state of partial asphyxy was produced, now becomes quick, short, irregular, and sono- rous. The patient sometimes screams, or utters the most unnatural and prolonged sounds, or the most extravagant expressions, but more frequently moans piteously; and the forcible expirations throw out a white tenacious froth, sometimes coloured with blood, over the lips. Tissot has observed the saliva sometimes to possess a cada- verous odour ; and Macbridf, and others have remarked, iu rare instances, blood to escape from the ears : epistaxls is more common. The pulse is often quick and small, but it is felt with diffi- culty; and is usually irregular, becoming more distinct, slower, anil more languid towards the close of this stage. The action of the heart is loud, vehement, or tumultuous ; and that of the carotids much increased. Flatus is often expelled involuntarily, sometimes with the faeces and urine; and the erection is occasionally followed by a discharge of semen, or of the prostatic secretion. At last the convulsions subside; fcetid perspira- tions break out about the head, neck,*nnd breast; the interrupted and convulsive respiration is fol- lowed by deep sighs; and the spasms of the muscles, by subsultus; vomiting or eructations sometimes occur, and the patient passes into the next stage. The duration of the first and second stages varies from less than one, to fifteen or twenty minutes. If they be prolonged beyond this, death is generally the consequence ; which, in the most violent cases, may also occur in the first stage, from the asphyxy occasioned by the spasm of the respiratory muscles ; or in the se- cond, from the degree of cerebral congestion and its more direct effects. 11. (c) The third stage, or that of collapse, is the most prolonged, and is characterised by a continuance of the loss of consciousness, by the disappearance of the convulsions, by the deep and often snoring sleep into which the patient falls, and by the gradual return of the sensibility, which may be now momentarily roused by power- ful excitants. The perspiration which had broken out at the close of the last stage becomes more copious and general, and continues for about an hour ; the pulse is now fuller, softer, and some- times slower ; the respiration freer and # easier ; and after awhile the patient awakes as* from a deep sleep, and is restored to perfect conscious- ness ; but is stunned, or wearied and exhausted, and complains of headache, or pain in the neck or occiput. Sometimes the eyes remain, for a considerable time, fixed, dull, or squinting, and the pupil enlarged. The patient has no recol- lection of what has passed. His speech often falters ; and he occasionally feels greater weak- ness in some one limb or other. These symptoms gradually disappear, but disinclination to exertion remains. 12. The duration of the whole paroxysm is ge- nerally from five or ten minutes, in the slight and imperfect cases, to three or four hours. M. Es- q.uirol has seen it continue five hours. I have seen it last more than four; and in one case seven hours, the seizure consisting of two fits, with an in- distinct interval of soporose exhaustion. The long attacks generally consist of two or more short fits, a slight remission taking place between each. The return of the fits is extremely various in dif- ferent cases. Several years may elapse between the seizures, as in a case in which I was recently consulted; or one, two, or three years may inter- vene. In a few cases, they have appeared every year at the same period, or even day. When they occur monthly, a stated day is more fre- quently observed, which often coincides with the new or full moon,— a coincidence much insisted on by Galen, Aret.sus,Arnold of Villanova, Gehler, Hoffmann, Mead, and others. The interval of a lunar month is more commonly no- ticed among females, from the connection of the disease with the uterine functions. In some in- stances, the paroxysms occur every week, on the same day; and occasionally every day, or night, at the same hour; but they most frequently come on when first falling asleep, and are often, for a time, unsuspected or overlooked. Sometimes several slight seizures take place in one day; but their recurrence is often extremely irregular. When they are neglected, they usually either become more and more severe, or occur after shorter intervals. Consciousness and sensation be- ing abolished, pain cannot be felt, during the fit. 13. The slight or imperfect seizures — the Petit Mai of French writers— are very varied in cha- 788 EPILEPSY — Consequences and Terminations. racter. They often precede, for months or years, the full evolution of the severe form of the dis- ease. Generally they consist of loss of conscious- ness, and slight rigidity, spasm, or convulsions of a few muscles, or of one or more limbs, which continue only one or two minutes. In still slighter cases, the patient is seized with vertigo, loss of consciousness and sensation, and muscular collapse or slight spasm of a few muscles, and is, after some seconds, completely restored. In some instances, the eyes of the patient become fixed and vacant; he attempts to articulate, but is un- able; loses consciousness for a very few seconds; and, upon recovering it, takes up the thread of discourse which the seizure may have interrupted, and endeavours to conceal the occurrence. Occa- sionally the slight seizures very nearly approxi- mate those of hysteria, or are associated with se- veral hysterical symptoms. In many instances, the patient does not fall to the ground, although he may have been standing at. the time of attack; and in others, consciousness is not entirely abol- ished, the patient retaining a vague recollection of whaf passed in the seizure, upon recovery from it, as after temporary delirium or dreaming. These slighter fits may recur either frequently or very rarely, but they commonly return after short in- tervals, and sometimes as often as several times a day. 14. D. Of the intervals between the paroxysms. —After the fit, the patient complains of lassitude, of soreness of the limbs and of parts that have been injured, and is pale, sad, and fearful of its return. In some severe cases, the face is studded, particularly about the eyes and temples, with numerous small ecchymoses arising from minute extravasations from the extreme capillaries of the rete mucosum during the congestion to which they bad been subjected in the paroxysm. In rare cases, vomiting or purging of blood is observed, owing most probably to sanguineous exhalation from the conjested capillaries of the digestive mu- cous surface. Sometimes paralysis of a limb, more or less complete, or strabismus, or even ir- regular movements or convulsions, or various hal- lucinations, follow the severer attacks, and continue several hours, or even days. In a case to which I was very recently called, paralysis of the left arm, and severe pain in the right eye-ball and temple, continued after the fit — the former for some hours, the latter for several days. Deaf- ness, watchfulness, terrifying dreams, slight or passing delirium, occasional convulsive move- ments (Aretjeus, &c), and fits of absence or forgetfulness, often afflict the patient, either for sometime after an attack, or during the whole interval. Between the complete parox- ysms, as well as before their evolution, the slight seizures, described above (§ 13.), in one or other of their forms — sometimes so slight as to amount merely to vertigo with momentary loss of con- sciousness, or spasm of some part — the Vertige Epileptique of French writers, are very common. Various signs of mental alienation often appear, which generally become more and more remark- able after successive, more frequent, or severer attacks, until insanity is the result. Epileptics commonly experience, during the intervals, vari- ous dyspeptic disorders ; but their appetites are usually very keen, and seldom duly restrained. J. Franx states, that he has seen persons suffer little disturbance after a fit, and others display increased activity of both mind and body, until its I approaching return ; but this is a rare exception ; the great majority, even of those who suffer the least, being incapable of devoting themselves to any undertaking with attention and perseverance 15. II. Consequences and Terminations. — Persons long afflicted by the disease, gradually acquire a peculiar physiognomy, owing to the re- peated distension of the vessels of the head, and to the frequent spastic and convulsive actions of the muscles of the face during the paroxysms. This is particularly the case in such as are ad- dicted to masturbation — a baneful practice which is common among epileptics, and, indeed, a prin- cipal cause of their malady. This alteration of the features has been noticed by Aret^us, who mentions their pale or leaden complexion, and their languid dejected look : but Dumas and Esquirol have described it most accurately. The individual features become coarse ; the lips thick ; the lower eyelids swollen; the eyes un- steady, full, and prominent; the look vacant; the pupils dilated; the cheeks pale; the finest counte- nances plain ; the muscles of the face subject to twitchings, or slight convulsive movements ; the arms and limbs thinner than the rest ofthe body; and the gait peculiar. The functions of organic life likewise languish, obesity or emaciation being a common result. When the disease appears or continues after puberty, or the fits return fre- quently, the mental as well as the bodily powers become greatly impaired. These consequences are, however, in some respects connected with the states of nervous function, and the circulation within the head directly producing the seizures ; ! the pathological conditions, which, at their com- mencement, and in slighter degrees, occasion the epileptic seizures, giving rise, in their advanced course and heightened grades, to various associa- ted maladies. After the continuance of the disease, the patient is at first listless, incapable of energetic exertion, and sometimes hypochon- driacal. He is liable to attacks of stupor, and complains of lassitude, flatulency; of various forms , of indigestion, generally attended by a craving appetite; of great torpor ofthe bowels; of vertigo and tremors, &c. He is subject to deafness, amaurosis, and, in prolonged cases, to irregular muscular contractions, or paralytic tremors, to partial paralysis or complete hemiplegia, to im- perfections or even loss of speech, to apoplexy, to melancholy, to partial or complete, or to in- termittent or continued insanity, and to mania and idiotcy. 16. Notwithstanding that epilepsy seldom passes into the apoplectic state, until after re- peated fits, yet both maladies may be associated in the very first seizure. (See § 40.) Insanity and mania, although not generally appearing until after several or many attacks, are by far the most frequent consequences of epilepsy; but I believe much more so on the Continent than in this country ; whilst apoplexy and paralysis oftener supervene here than there. Van Swie- ten states, that persons who have become in.sane at an early age, have been generally first epileptic. Esquiroi. has come to a similar conclusion; and my experience confirms it; the seizures, howr ever, having been sometimes of an irregular con- vulsive kind, rather than those of true epilepsy. In EPILEPSY —Causes. 789 this frequent class of cases, the mental faculties are gradually impaired; sensation and memory are weakened, the former being often acute; Serception and imagination perverted; various allucinations generated; and the patient lapses Jito a state of incurable insanity or imbecility, or passes from the former into the latter. The more severe the fits, the more is this result to be dreaded. Sometimes violent attacks of mania follow the paroxysms. Of 289 epileptics in the SalpBriere, in 1813, 80 were maniacal, and 56 in various states of mental alienation and imbe- cility. In 1822, out of 339 cases in the same hospital, there were 2 monomaniacs, 30 maniacs, 34 furious maniacs, 129 insane for some time after the paroxysms, 16 constantly insane, 8 idiotic; 50 upon the whole re;isouable, but with impaired memories, and liable to occasional slight delirium, and tendency to insanity; and 60 without aberration of intellect, but suscep- tible, irascible, capricious, obstinate, and pre- senting something singular in their characters. As this institution receives chiefly old and severe cases of epilepsy, it furnishes sufficient illustra- tions of the consequences of this disease. Occa- sionally the epileptic mania alternates with me- lancholia and a desire to commit suicide; the mania often preceding the paroxysm. Dr. Cheyne states that he has known epileptics pre- serve their intellects to a very old age; but this is only the exception to the general rule, for they seldom live to a great age, or retain their facul- ties when they reach it. 17. The duration ofthe disease is most uncer- tain and various, and depends upon numerous cir- cumstances connected with the regimen, habits, and treatment of the patient. Epileptics are most injuriously addicted to the indulgence of the appetites for food, and for the sex,—practices which should as much as possible be guarded against, as tending not merely to counteract the good effects of treatment, but also to induce the unfavourable consequences of the seizures enu- merated above. A favourable termination is in- dicated by the fits being slighter, shorter, and more distant. Sometimes a marked crisis occurs —as the return of a suppressed evacuation, partic- ularly the menstrual and haemorrhoidal fluxes, epi- staxis, &c, the reappearance of a repelled erup- tion ; &c. An attack of continued fever has re- moved the disease, — but very rarely when it has become confirmed. M. Esquirol states, that in 18t4, when typhus fever raged in the Salpetriere, although upwards of fifty epileptics were attacked by it, and but few died, little or no amelioration was observed in any. 18. A person subject to epileptic fits may die of other diseases, or of a malady proceeding from an increased grade of the same changes, which, in a less degree, occasioned the fits; or of the direct or indirect effects of the repeated seizures; death taking place sometimes in the intervals, but more frequently during the paroxysm or soon afterwards. When it takes place in the interval, it is occasioned by the remote effects ofthe fits, in connection with the pathological states inducing them — by some one of the diseases consequent upon them (§ 38. et seq.). If it occur during or soon after the paroxysms, it is generally owing to an augmented degree of the same changes usually producing them, or to some further alter- | ation directly proceeding from these changes; either apoplexy caused by excessive congestion within the head, or by extravasation of blood in some situation, or by effusion of serum in the ventricles or between the membranes of the brain; or asphyxy occasioned by similar lesions affecting the medulla oblongata and upper part of the spinal cord, being the immediate cause of dissolution. It has been supposed, that suffo- cation often occurs in the paroxysm, owing to the position of the patient, or of the clothes around him when in bed. But this, I believe, rarely takes place; and when suffocation, or rather asphyxy, is met with, it is caused chiefly, if not altogether, by some one of the changes just stated. 19. III. Causes.— i. Predisponent.— Heredi- tary disposition is a remarkable predisposing cause of epilepsy, notwithstanding this kind of influence has been disputed in respect of it. But although the father or mother of the patient may never have had an attack, either of the grand-parents, or | uncles, or aunts, may have been subject to it. Zacutus Lusitanus (Prax. ad Mir. 1. i. obs. 36.) mentions the case of an epileptic man who had eight children and three grandchildren afflicted by the disease. Stahl ( De Hared. Dispos. ad var. Affect. Hake, 1706,p.48.)andREiNiNGER ! adduce instances of the whole of the members of a family being attacked by it at the period of puberty. Boerhaave (Aphorisms, 1075.) remarks that, like several other hereditary maladies, it often pas- ses over alternate generations; and he adduces an instance (Prax. Med. t. v. p. 30.) in which all the children of an epileptic father died of it. I had, in 1820, a brother and sister some time under my care, who inherited the disease from their | father, and they had two other brothers and one sister also subject to it — in all five. The fits appeared in all of them about the period of puberty; and one of the brothers died about the age of forty, from apoplexy, complicated with the I seizure. MM. Boucher and Casauvieilh state that, in 110 patients, respecting whom they had made the enquiry, 31 were hereditary cases; and M. Esquirol found, that in 321 cases of ep- I ileptic insanity, 105 were descended from either j epileptic or insane parents. Predisposition is often j connected with congenital formation. I have seen the disease in several children, whose heads were of an oblique or diamond shape, or other- wise ill-formed; one side being more elevated than the other, and either side advancing or receding. Peculiarity of constitution, or idiosyncrasy, seems to predispose to it, as well as the epochs of child- hood and puberty, at which periods the nervous and muscular systems are endowed with their greatest sum of sensibility and irritability, and the whole frame with great susceptibility. Cases, I however, often occur in which these properties are rather diminished than increased. After I puberty is fully attained, the disposition to the I disease is greatly lessened. 20. The influence of sex is not remarkable; and is not manifested until after the second den- tition. According to Esquirol and Foville, females are more subject to the disease after this epoch than males. At the end of 1813, 162 } male epileptics were in the Bicetre, and 289 fe- male cases in the Salpttriiire. J. Frank found, j that of 75 patients, 40 were females; but he agrees 790 EPILEPSY —Causes. with Celsus, Heberden, and Soemmerring, in believing, that if a strict diagnosis were estab- lished between this and other convulsive diseases to which females are very liable, particularly sev- eral of those seizures described in the article Con- vulsions, the predominance would be found on the side ofthe males; and Drs. Cooke, Elliot- son, and Cheyne are of the same opinion. MM. Bouchet and Casauvieilh ascertained, that of 66 female epileptics, 38 were seized before their first menstruation, and 28 subsequently to that epoch. I agree with M. Foville in thinking the disease more prevalent in the lower than the upper classes. M.Esquirol states, that the melanchol- ic temperament is more disposed to it than any other. Dr.PRicHARD seems nearer the truth, in saying than it is common to all temperaments and habits, but it is not equally common to all. Dr. Cooke remarks, that almost every case he has seen has occurred in sanguine temperaments and plethoric habits. This does not agree with my ex- perience, which leads me to infer that it is most fre- quent in persons who are either very plethoric or very much the reverse. Its greater prevalence in persons of a scrofulous and rickety diathesis, than in any other,has been shown by Hufeland and Portal, and is undoubted. J. Frank remarks, that more than half the cases in his practice were strumous. Dr. Cheyne would make the propor- tion even larger. De la Fontaine and Frank found epilepsy extremely common amongst those born of parents affected by the Plica Polonica. An exhausted state of frame occasioned by what- ever means, a cachectic habit of body, the syph- ilitic and mercurial poisons, and scorbutus, also dispose to the disease. Great activity of the men- tal faculties, and an exalted or excited state of mind, may predispose to it; and in proof of this, the circumstance of Julius C^sar, Maho- met, Petrarch, Column a, Francis Rhedi, Rousseau, and Napoleon, having been subject to it, has been adduced by authors. But in men of strong minds, and powerful talents, the disease has seldom or ever occurred until the nervous energy has been exhausted by exertion, or by the excitements and anxieties of life. Suetonius (1. i. cap. 45.) states, that it was only in the last part of his life that Cesar was seized with epi- lepsy; and that he had two attacks while he was engaged in business. It seems more prevalent in some countries than in others. This has been referred to peculiarity of climate, especially to cold and moisture. It is more evidently dependent upon moral causes, particularly to excessive and premature venereal indulgences, which are more common in some countries than in others; the disease being very prevalent in the South of Russia and Germany, in Poland, in Italy, and France — certainly much more so than in this country and the United States. Hippocrates and Tissot think it most frequent and severe in spring, but this is not remarkably the case, and has been denied by several writers. 21. It has been asked, Whether or no this disease is more common now than formerly ? The dissolute habits ofthe ancient Greeks and Romans lead me to infer that it was at least as prevalent among them as with us. Panaroli states, that it was very frequent among the rich and noble Romans, particularly during the acme and decline of their greatness, when the utmost luxury, dissipation, and debauchery prevailed among the higher classes under the emperors. 22. ii. The occasional Exciting Causes are re- markably numerous and diversified. Various circumstances may concur in exciting the first seizure; and where no marked predisposition to it exists, a concurrence of several causes is requi- site to its production; but, when once produced, a single, and even a slight, cause may occasion subsequent attacks. This class of causes acts variously :— 1st, Many directly change the phy- sical condition and circulation of the encephalon; — 2dly, Others affect the organic nervous in- fluence and circulation of the brain, through the medium of the sensations, perceptions, and other operations of the mind;—and, 3dly, Some act upon various remote organs or parts; the brain and nervous system being only consecutively and indirectly affected.— (a) Injuries of the head; fractures, depiessions of a portion of one of the bones of the cranium, concussions of the brain or spinal cord; tumours, and the numerous pathological changes in the brain, its vessels, and its membranes, or in the cranium, described in the articles Brain, and Cranium; partial or general inflammation ofthe brain, or of its mem- branes; diseases of parts immediately adjoining, as of the cranial bones, the scalp, the medulla oblongata, and spinal cord, the ear, eye, &c, or of the vertebra;, &c. ; excessive haemorrhage and discharges; hypocatharsis, or blood-letting carried too far; omitting accustomed and requi- site evacuations; insolation; the suppression of otorrhcea, of porrigo, and other eruptions; pro- longed sleep; and the metastasis of gout or rheumatism to the encephalon; are the principal causes which act in the first mode pointed out. — (b) All inordinate affections of the mind may induce a seizure in persons predisposed to it, either by exciting the nervous influence and cerebral circulation too far above the natural pitch, as joy, anger, fits of indignation, coition, &c. ; or by depressing the one or retarding the other to a degree incompatible with the continu- ance of the vital functions — as terror, sudden alarm, grief, protracted anxiety, a sense of dis- gust, the impression of various odours, excessive mental application or exertion, &c, nostalgia, disappointments, unrequited or forbidden affec- tions, longings after objects of desire, or love, &c. Prolonged want of sleep; very great or enduring pain; difficult dentition; great surprise; frightful dreams; appalling and distressing sights; seeing others in the paroxysm; nervous irritation, titil- lation, whirling rapidly round; excessive sexual intercourse and masturbation ; ill-controlled states or flights of imagination, &c. ; are also very common and powerful causes. M. Esquirol, whose experience in this disease has been un- equalled, truly states that fits of passion, dis-' tress of mind, and venereal excesses hold the next rank to terror, &c. in exciting the dis- ease.— (c) The causes which act in the third mode are extremely numerous; persons who have become subject to the disease often ex- periencing a seizure from very slight occurrences. The most common are, however, the indulgence in too much, or in improper food; a heavy meal taken shortly before retiring to rest; the use of spirituous and fermented liquors, or of coffee, in excess; very high temperature, impure air, and EPILEPSY —Varieties. 791 crowded assemblies; exposure to great cold; irritation of worms or morbid matters in the prima via; various acrid, narcotic, and acro- narcotic poisons, &c. There are several causes, the operation of which is either not well known, or connected with the diathesis and peculiar pre- disposition ofthe patient; and others—as, indeed, many of those just enumerated—which manifestly act in more than one of the ways pointed out above. The most remarkable of these are disorders of other organs or parts, particularly functional or structural diseases of the heart, of the digestive canal, of the liver, and of the generative or urinary organs; the presence of a calculus in either the kidney, the ureter, or bladder (Bartholin, De la Motte, Brendal, Salvages, &c), or of a gall stone in the ducts (Jens, Blames, &c); the irritation or lesions of remote nerves; the syphilitic and mercurial poisons, &c. (Larrf.y). 23. Dr. Hebreard ascertained that, of 162 male epileptics in the Bicetre at Paris, 119 were unmarried, 33 married, and 7 widowers. Ac- cording to LocHKR(06seri\ Pract. inVien. 1736, p. 36.), out of 80 cases, 60 were occasioned by frights of various kinds and degrees : but, of 69 cases, MM. Bouchf.t andCASAUViEiLH found only 21 that could be referred to this cause. The excitation of the feelings or passions pro- duced by dramatic performances has also brought on an attack. J. Frank states that, before epi- leptics were separated from the other patients in the wards ofthe Civil Hospital in Vienna, it was not uncommon for some of the other patients to be seized with the disease from sympathy or imitation upon seeing the epileptic paroxysm. This has been observed by Baglivi (Opera, 1. i. cap. f4.), LETTSOM(Mem. of Med. Soc.of Lond. vol. iii. p. 383.), Duncan (Med. Cases, Edin. 1778.), Aaskow (Coll. Soc. Med. Haun. vol. ii. p. 14. 22.), Meza (Comp. Med. Pract. fasc. v. p. 15.), and Hardy (Lond. Med. Gazette, vol. xi. p. 247.). I have seen it occur in one instance; but I believe that the form of con- vulsion described in § 17, 18. of that article is more frequently produced by this circumstance than true epilepsy, unless in persons liable to this malady. Various writers, particularly Galen (De Diebus Criticis, 1. iii. c. 2.), AretjEus (De Caus. et Sig. Morb. 1. i. c. 4.), Alexander Trallianus(1.l c. 15. 21.),Ca m er a rius (Me- morab. cent. ii. n. 38.),Riverius, F. Hoffmann (Institut. 1. iii. c. 88.), Stahl, Mead (De Imp. SolisetLune, fyc. Lond. 1704.),WF,DFL(2?pAem. Germ. An. ii. decur. 2. obs. 148.), Rumpf.lt, Burmestf.r (De Morbo Spastico, fyc. Goet. p. 21.), Otto (De Planet, in Corp. Hum. Influxu. Franc. 1805.), have insisted upon the more frequent occurrence of the paroxysm at the periods of new and full moon than at any other. Indeed, lunar influence on this disease seems to have been generally believed in by the ancients; and hence one of the names given to it by them. The supervention of epilepsy during the early stages of the exanthemata, or upon the disap- pearance of the eruption, is much more rare than stated by many writers; for the seizures tiiat sometimes take place in such circum- stances are more strictly symptomatic convul- sions, and seldom return afterwards, unless in those much predisposed to this disease. A simi- lar remark also applies to the violent convulsive attacks, which occur during, or about the period of, parturition; and which, although they possess most of the characters of epilepsy, particularly of the uterine variety, do not necessarily return at any other period, or even on a subsequent confinement, unless in females who are really epileptic, who are very liable to dangerous seizures at this particular time. 24. Various nervous diseases sometimes pass into epilepsy, either of a simple or complicated form, — most frequently the latter. Hysteria, chorea, catalepsy, cataleptic ecstasy, somnambu- lism, and symptomatic attacks of convulsion, when neglected or improperly treated, occasionally ter- minate in confirmed epilepsy, with various asso- ciated disorders, and not infrequently in some one of the complicated states hereafter to be noticed. Numerous affections of the digestive orgtins have been assigned by writers as exciting causes. But I consider them, with the exception of worms in the prima via, which are a frequent cause, particularly in children, as coexistent with, or contingent upon, the commencement of that state of organic nervous power and circula- tion in the brain producing the disease, and that the disorders of the digestive organs, as well as this early state of cerebral affection, equally depend upon deranged vital manifestation through- out the organic nervous system. 25. IV. Varieties of Epilepsy.—Various divisions have been proposed with the view of fix- ing with greater precision the treatment which is most appropriate to the different phases of the complaint. Aretjeus and other ancient writers distinguished it by the terms acute and chronic. One of the most commonly adopted divisions is that into idiopathic or cerebral, and sympathetic or originating in disorder of some other organ. Piso long ago doubted the existence of the sym- pathetic disease, and MM. Georget and Bos- quillon have adopted his opinion. These writers contend, that the sensations, or disordered feel- ings manifested in remote organs, may actually have their seat in the brain; and that the aura felt in a distant part may depend upon an original cerebral affection. Those who believe in the sympathetic forms admit that the seat of the paroxysm is always the encephalon; its cause, or the disorder which excites the cerebral affec- tion, on which the seizure depends, being often in other organs. Hence they subdivide the sympa- thetic species into as many varieties as there is disorder manifested in other organs — into the spinal, the cardiac, the gastric, hepatic, intes- tinal, nephritic, genital or uterine, the nervous, &c. Sauvages and SagaR(Systema Morborum, Sfc. p. 442.) make as many varieties as there are principal exciting causes. Vogel (De Cog- nosc. et Curand. Corp. Humani Affectibus, p. 404.) notices the cerebral, that depending upon disorder of the digestive organs, and that aris- ing from irritation of other parts. Dr. Cullen admits two species, the idiopathic and symptoma- tic — and distinguishes the former into the cere- bral, the sympathetic, or that attended by aura, and the occasional, or that arising from some ir- ritation; the latter into as many varieties as there are organs occasionally originating the disease. Dr. Good mentions three species—the cerebral, the catenating, and complicate. Dr. J. Frank views epilepsy in connection, both with the organs 792 EPILEPSY —Simple —Sympathetic from which it seems to derive its origin, and with the states of action it manifests: these states he divides as follows—the atonic, traumatic, in- flammatory, rheumatic, metastatic, arthritic, car- dnomatous, gastric, scrophulous, syphilitic, and complicated. These distinctions are too compli- cated and unavailable in practice — are, in truth, as respects several of them, distinctions without differences. The arrangement adopted by Dr. Prichard is deserving of attention, as it com- prises several of the most important sympathetic associations and complications of the disease; that, followed by Dr. Cheyne, presents nothing novel or requiring remark. The division which Beems to me most accordant with the states it com- monly presents in practice, is that into—1st, its Simple forms; 2dly, its Sympathetic varieties; and 3dly, its Complications. 26. i. Simple Epilepsy, Epilepsia Simplex — Primary Epilepsy; E. Cerebralis, Idiopathica, Essentialis, Legitima, Primoria, Encephalica, Auct. varior.— may present itself in various forms, as respects nervous susceptibility and vascular ful- ness and action.—It may occur in emaciated persons, whose nervous energy has been ex- hausted, and whose blood is deficient in quantity and quality, or in those who are plethoric and apparently robust. It may present symptoms of imperfect or sub-action, in connection either with deficiency, or with too great fulness of blood; or of increased action, especially as respects parts about the base of the encephalon. It is very im- portant in practice to ascertain these states of the vascular system, as upon them must necessarily be founded the chief indications of cure. 27. A. Simple Nervous or Asthenic Epilepsy— E. Simplex nervosa, or Epilepsy with defective power and action — is not so common in this, as in other countries; yet it is not infrequent in London and large manufacturing towns.—It is observed in weak constitutions; in thin habits, presenting a deficiency rather than fulness of blood; in young persons employed in factories; and in those who are endowed with great suscep- tibility, and who have been addicted to venereal excesses, especially to onanism. In this form, the face is pale or sallow; the veins small; the pulse weak, small, and accelerated, or readily excited; the seizures are frequently ushered in by leipothymia or fainting; and the countenance is neither full nor livid, until the convulsive stage of the fit, and often not even then. It is probable that, at the accession ofthe attack, the due sup- ply of blood to the brain is withheld, or the cir- culation of it interrupted; although it must be ad- mitted that there may be evident want of nerv- ous power, and general deficiency of blood, and yet vascular action may be increased within the head, relatively to the rest of the body. It is very important in practice, to ascertain which of these states exists on the accession of the fit; and this can be done only by examining the circulation in the carotids, the temperature of the head, and the action ofthe heart, at this and at other periods. This state of the disease may ultimately become complicated with insanity, imbecility, or paralysis. 28. B. Simple Sanguineous Epilepsy — E. Simplex Sanguinea; Acute Epilepsy, Loben- stein-Lobel and Richter ; Epilepsy with Plethora; E. Plethorica, Portal and others; E. unth exdted or sthenic adion; E. with deter- ■■ mination of blood—appears to be the most common form of cerebral epilepsy, especially in this country.—It is usually observed in san guine and plethoric habils, and is consequent upon too high living, great exertion, the suppres- sion of accustomed evacuations and discharges, the disappearance of eruptions, or the translation of morbid action from other structures to the brain, exposure to the sun, and violent fits of passion. In these, as in other cases betraying increased vital action, the disease has been sup- posed by several writers to possess an inflamma- tory character—E. Inflammatoria, J. Frank, Portal, and others. — There is every reason to suppose that this form is caused by an impeded return of blood from the head, as well as by in- creased determination to it; and that it is more frequently associated with disordered action of the heart and congestion of the liver, than is generally supposed. Although simple plethora, or determination of blood to the encephalon, may alone be sufficient to the production of the fits, yet these states will ultimately be followed, if the disease be not arrested, by partial or slow forms, of inflammatory action; and, con- sequently, in protracted cases, the malady will often pass into, or be complicated with, mania, phrenitis, apoplexy, or paralysis. In other cases, owing to the constitution of the patient and the nature of the exciting causes, the disease is ob- viously connected, from the commencement, with chronic inflammation of a partial or limited kind, inducing alterations chiefly in the medullary sub- stance of the brain. The distinction, made by Sauvages, Sagar, J. Frank, and others, between the inflammatory, the rheumatic, the me- tastatic, and arthritic states of the disease, are not to be discovered in practice; as they all present signs of determination of blood to the encephalon, and of excited action: but it is of importance to keep these morbid relations in re- collection, as they should very materially influ- ence the treatment. The countenance in the fit is generally red, tumid, or livid, and is, with the head, covered by perspiration; respiration is at first interrupted, and afterwards sonorous and laboured; the convulsions are not very violent, nor of long duration; and the subsequent stupor is profound and prolonged. In the intervals, the patient is subject to vertigo, or temporary loss of consciousness. The Syphilitic, Scorbutic, Ca- chectic, Humoral Febrile, &c. of Bonet, Hoff- mann, Sauvages, &c. are merely occasional symptomatic or complicated states ofthe disease, the paroxysms often closely resembling those of simple convulsions. 29. ii. Sympathetic Epilepsy; E. Sympathica; Epilepsy with associated disorder of other organs. —This form is much more varied than the fore- going, not only as particular organs may betray disorder antecedent to, or coexistent with, or consequent upon, the explosion of the epileptic attacks; but also as it may present more or less of the features of either of the. two states just particularised; epilepsy associated with especial disorder of some important organ, being, in re- spect of nervous power and vascular fulness, also either nervous or sanguineous, as described above (§ 27, 28.)—being oftener further characterised by defective tone and energy, and deficient fulness of blood, or by plethora and excited action. This EPILEPSY — Sympathetic. 793 very important connection of morbid states, al- though appearing complex to the superficial ob- server, will not seem so to those who are in the habit of pathological analysis. It is chiefly owing to the circumstance of this species of in- vestigation having been neglected as respects epilepsy, and to our consequent ignorance of the actual state of the circulation within the head, and of the heart's action, about the accession of the paroxysm, that our knowledge of the nature and treatment of the disease has advanced so little since the days of Aret^eus. 30. A. Epilepsy from affection of the spinal cord—E. Spinalis of J. Frank—has been elaborately described by Harles (Opera Min. ac Med. t. i. 1825.). It generally arises from injuries and concussions of the spine; from caries of the bodies of the vertebrae, or inflammation ofthe intervertebral substances; and from inflam- mation of the membranes of the cord, or effusion of fluid within the sheath, from the metastasis of rheumatism, or the disappearance of eruptions, &c.; and is sometimes preceded by great sensi- bility, formication, or irritation of the skin. The fits are generally characterised by severe convul- sions, seminal emissions, and relaxation of the sphincters. The head is seldom so much affect- ed as in cerebral epilepsy, and the seizures often approach nearly, or altogether, to simple convul- sions. One or other of the limbs is frequently weak, and sensation in them occasionally dimin- ished, or otherwise altered, during the intervals. Mr. Austin and myself lately attended a young lady, in whom the catamenia returned every fort- night in large quantity; and who afterwards had slight epileptic seizures. We found the spinous processes of the three upper lumbar vertebra projecting, and that part of the spine painful, ind tender upon firm pressure and percussion. The case terminated favourably from the treat- ment advised in this state. I believe that disease of the spine, associated with disorder of the ute- rine functions, and epilepsy or convulsions, is not rare. This form of epilepsy may be attended by great nervous susceptibility and deficiency of blood, as in the case now referred to ; or by sanguineous plethora or excited action; either of the two'pathological states characterising the sim- ple malady also subsisting in this. 31. Very intimately connected with this variety is the supervention of the seizures upon pressure, irritation, laceration, or other injury of nerves. As in the spinal variety, so in this, the paroxysm, generally, is rather one of convulsions than of complete epilepsy. I do not believe that this and the spinal variety are more frequently pre- ceded by an aura than the other forms; as this sensation may not depend upon any change in the part in which it seems to originate, but upon the condition of that portion of the brain or cord with which its situation is especially related. I have even met with cases in which the aura shift- ed from one limb to another in the course of treatment. 32. B. With especial disorder of the circulat- ing and respiratory actions.—(a) I believe that the paroxysm is more commonly connected with disordered function of the heart, than is generally stated by writers. In many of the cases where I have had an opportunity of examining the state of the circulation, just before, or at the com- 67 mencement of, the fit, the action of the heart has been either suspended for a few seconds, or re- markably slow or irregular. This connection has not been overlooked by some authors. Q,u erce- tanus (Tetrad, de Affect. Capitis, cap. 8.), in- deed, assigns to this organ the seat ofthe disease; and instances have been adduced by Morgagni (Epist. Ixiv. art. 5, 6.), Lancisi (De Mortib. Su~ bitaneis, p. 113.), Gould (Philosoph. Trans, vol. xiv. p. 537.), Sprengel, and Brera (Krank. d. Herzens. fyc), in which the seizures com- menced with fainting, followed by palpitations; and, after death, the cavities of the heart were found dilated, and containing fibrinous concretions. The numerous dissections of Greding also show the frequent connection of the disease with lesions of this viscus. (See § 47.) Dr. Reid has drawn attention to the subject in a more especial manner than any other writer, but in too general terms. " It will be found," he states, " that the first symptom of an attack is the suspension of the action of the heart; and, consequently, an inter- mission of the pulse, which may continue from a few seconds to about three minutes; which was the longest period of intermission I have yet seen." i I noticed the affection of the. heart in a young I man, whom I attended in 1820; and in several cases since that time. But opportunities are com- paratively rare in which the physician can exam- ine the patient at or shortly before the accession | of a fit. That the heart's action is interrupted at | this period, in many cases, appears evident, on observing the symptoms, and tracing the connec- tion between the exciting causes and their more immediate effects. When we consider that the most common and energetic causes, as fright, surprise, grief, anxiety, &c, are those which, al- though primarily affecting the cerebral functions, most remarkably disorder the actions of the heart, the importance of more frequently directing out attention to this organ, in our researches respecting the nature and treatment of epilepsy, will be evi- dent.—(b) The disease can hardly be said ever to depend upon disorders of the lungs; although the function of respiration is very often remark- ably affected, or even altogether arrested, owing to the sudden spastic contraction of the respira- tory muscles in the first period of the paroxysm; and cases sometimes occur in which the frequent congestions of the lungs, from this cause, are pro- ductive of inflammation, or hepatisation, or even of effusions into the pleura?. But such associa- tions are merely consecutive; and are chiefly met with in prolonged and complicated cases, as shown by the researches of Greding. (§ 47.) 33. C. With disorder of the digestive organs. —(a) When the stomach is the organ chiefly dis- ordered— the Epilepsia Stomachica of Sauva- ges, Cheyne, &c; the E. Gastrica of Frank and others—there are generally a loaded tongue, heavy or disagreeable breath and perspiration, unpleasant taste, acrid or acid eructations, car- dialgia, a sense of distension at the epigastrium and hypochondria, and morbidly increased or even ravenous appetite; digestion being at the same time very slow and imperfect, especially just before the paroxysm. In some instances, the appetite is capricious or defective; and, occa- sionally, nausea and even vomiting occur. Not infrequently, large quantities of undigested food, some of which was taken two or three days pre- 794 EPILEPSY —Sympathetic. ■viously, are vomited shortly after the fit. The bowels are usually torpid. This form, particularly in the paroxysm, generally assumes the character ofthe sanguineous or plethoric variety (§ 28.). 34. (b) Where the biliary organs especially betray disorder—the Epilepsia Hepatica of Bur- serius, Prichard, and several nosologists — pain, fulness, or tenderness in the right hypochon- drium, or towards the epigastrium, with flatulence, occasional hiccup, or quickened respiration, and a sallow or icteric countenance, are complained of, generally some time before the explosion of the paroxysm. Burserius has seen the disease follow the formation of biliary calculi. It seems, from my own experience, to be connected more frequently with jaundice than with any other form of biliary disorder; and to possess more of the plethoric, or sub-inflammatory form, than of the nervous (§ 27, 28.). 35. (c) Epilepsy arising from, or associated with, disorders ofthe bowels—the E. Ent erica of Prichard—more especially with worms in the intestines—the E. Verminosa of nosologists—is very common, particularly in children. It may commence in the form of convulsions, and be- come fully developed after several seizures; or it may be complete from the first attack, especially in the scrofulous diathesis. Although it most frequently depends upon worms, it may be con- nected only with an accumulation of morbid se- cretions, or faecal and undigested substances, in the intestinal canal. The tape and lumbricoid worms are those which oftenest induce it; and, where this cause exists, the symptoms of worms are usually observed. When it occurs about the period of second dentition, or about that of pu- berty, it is often a most severe and obstinate dis- ease. It is very frequent among the poor and ill-fed. Autenrieth states, that more boys than girls are affected by it. It is with difficulty dis- tinguished from convulsions, into which it almost insensibly passes; but, according to my expe- rience, which, especially as respects children, has been very extensive, it is not so common as the different forms of Convulsions. (See that article, § 24.) Monschein (De Epilepsia. Franc. 1700, p. 9.) and J. Frank consider true epilepsy from worms comparatively rare. The paroxysms, in thin and weak patients, generally commence as in the cardiac variety; or with vertigo and leipothymia, the action of the heart apparently being momentarily suspended, and the countenance pale and collapsed. In some in- stances, where the habit is more plethoric, the face becomes tumid, livid, or injected. The at- tack is often preceded by pain in the abdomen, or by nausea or vomiting; and occasionally by an aura ascending from the umbilicus. The bow- els are generally constipated; but sometimes the constipation alternates with diarrhoea, the evacu- ations being unhealthy, crude, and offensive, and often containing little or no bile. The appetite is also craving, ravenous, and unnatural; and the skin is foul, or the seat of chronic eruptions. 36. (d) In these varieties, the disorders of the digestive organs may be more or less concerned in producing the disease; or both the one and the other may be coexistent, or the associated consequences of impaired vital energy, mani- fested in the organic nervous and vascular sys- tems, particularly of those organs which evince most disturbance (§ 47.). In some cases, as in those related by Morgagni (Epist. ix. art. 7., et Ep. Ixiv. art. 5.), and by Sir W. Burnett, it is difficult to determine whether the heart, the liver, the stomach, or the bowels, present great- est functional disturbance. But, besides these, other parts concerned in the functions of diges- tion and assimilation may also betray disorder, as the spleen, pancreas, and mesenteric glands. These affections, whether they be viewed as con- current exciting causes, or as associated effects of impaired health, are deserving of attention in practice, as their increase or diminution will very materially affect the disease; treatment being of little service, unless directed with strict reference to them. 37. D. With disorder of the generative or urinary organs.—(a) Epilepsy is most frequently either excited by, or associated with, disorder of the female organs, especially the uterus — the Epilepsia Uterina oi Eickmeyer, Gruger, Sauvages, Prichard, and Cheyne—or.with irritation of the adjoining parts, as of the ovaria, vulva, &c. It may be further associated with hys- teric symptoms—the E. Hysterica of Wed el, Schulze, &c; and the E. Nervosa of Dr. Cheyne. But these are merely phases of the same variety; aud not different species, as describ- ed by some recent writers. Uterine epilepsy sometimes proceeds from delayed, or difficult, or obstructed catamenia, and generally returns about the menstrual period. Frequently, the same causes which disorder the uterine functions, also induce this disease; as sudden alarms, terror, anxiety of mind, manustupratio, disappointed love, nostalgia, great fatigue, cold applied to the lower parts of the body, &c. This variety is most common about, or soon after, the period of puberty; and in young females of a sanguine temperament, light eyes, ruddy complexion, and plethoric habit of body; and is associated not only with difficult or suppressed menstruation, but with various symptoms of irritation of the uterine organs, or with too frequent or excessive menstruation. I have remarked that the paroxysm oftener occurs after the subsidence of the menstrual evacuation than either before it or during its continuance; and that the fit commonly commences in the leipothyrniac or cardiac form. Although hysteri- cal symptoms are observed in other varieties of the disease affecting females, yet they are most common in this, especially in nervous and delicate constitutions. These symptoms are, vertigo, faint- ings, palpitations, the globus or clavis hystericus; pain about the sacrum, under the left breast, or in the left side, or in either mamma?; large evacuations of pale urine; borborygmi; and occasional hysteric delirium.— (b) The irritation of calculi in the kidneys or urinary bladder may likewise be connected with epilepsy; but I agree with Frank in thinking that this disorder induces convulsions more frequently than gen- uine epilepsy. This latter is more commonly associated with great irritability of the male organs, both affections having been brought on by masturbation; inordinate excitement, whether mental or physical, occasioning a paroxysm. There are few states of the disease which oftener present extreme fulness, or deficiency of blood than this. 38. iii. Complicated Epilepsy—E. Complicata. EPILEPSY —Complicated. 795 —Besides the association of diseases of distant parts with epilepsy, various important compli- cations of other maladies of the nervous system with it, very frequently present themselves in practice. In most cases, the complications are of the kind above noticed (§ 15, 16.)—are merely consequences of an advanced grade of the same changes upon which the epileptic praoxysms seem to depend, or these heightened by the effects of the repeated seizures. But in others, different affections of the nervous system long precede the occurrence of an attack; and in some instances the complication is manifested from the com- mencement; and occasionally, even the first or second seizure is of a mixed kind. 39. (a) The most frequent complication is that with mania and other forms of mental alien- ation. Much attention has been paid to this state of disease by Continental writers, particu- larly by Eso.uirol, Greding, Guisi.ain, Frank, Calmiel, Bouchet, Casauvieilh, and BouiLLAUD,and by Dr. Prichard. The mental disorder generally appears in the course of prolonged cases, and at first immediately after the seizures, in an intermitting form, and as stated above (§ 15,16.); but it is occasionally the original affection, the epileptic paroxysms supervening in the most protracted and hopeless cases of insanity, imbecility, or idiotcy. When it occurs early in epilepsy, the fits usually pass into a maniacal state of delirium, remaining longer or shorter after each, until continued and confirmed insanity is the result. This complication is sometimes congenital, and is then often connected with mal- formation of the cranium. It very frequently seems to depend upon chronic or sub-inflamma- tory vascular excitement in the encephalon, affecting chiefly the cortical and medullary struc- tures of a part, or parts only; and is often further associated with diseases of either the heart, the digestive canal, the biliary organs, or the uterine functions, as shown by the instructive researches of Greding, Prichard, Bright, Bouchet, and Casauvieilh.—This state of disease may even ultimately pass into apoplexy or paralysis, before it terminates fatally. 40. (6) The apoplectic complication may occur as stated above (§ 16.18.), or the very first seizure may be a combination of apoplexy with epilepsy. Of this latter, I have seen two cases within six months of writing this;—one, that of a female of middle age, attended by Mr. Byam; the other, that of a corpulent man of sixty three years. The former of these recovered, the latter died. When the apoplectic and epileptic seizures are thus associated, the distinctive features of either may precede those of the other. In the two cases now alluded to, the seizure was apo- plectic at its commencement, the true epileptic convulsions not appearing until after some time; but more frequently the apoplectic phenomena supervene upon the epileptic fit. Partial or ge- neral convulsions are not infrequent in the course of an apoplectic attack. But these do not con- stitute the coinpFication now being considered; for in it, the stages of the epileptic fit, as described above, with the characteristic phenomena—injury ofthe tongue, priapism, &c.—are clearly defined. In this kind of seizure, one or more limbs, or one half the body, may be paralysed; but as often, this additional affection is not observed. The severe forms of convulsions which occur in the puerperal states sometimes very clearly approach, or are altogether identical with, this complication. But they are rarely connected with paralysis. Not- withstanding the obvious relation between epilepsy and apoplexy, and their frequent complication, the subject has been unaccountably overlooked, even by practical writers; it having been incidents ally noticed only by a few, until Dr. Bright directed attention to it (Med. Reports, vol. ii. pp. 198. 519.). Hippocrates (TTeoi \i8iriov, § ix. v. 103.) seems, however, to allude to it; and his commentator, Martianus (Annot. in Lib. Hip. de Gland, v. 103.), Morgagni (De Sed. et Caus. Morb. ep. iv. sect. 4. 5. et ep. ix.), and Dr. Prichard (On Nerv. Dis. p. 59.) mention it somewhat more explicitly. 41. Nearly allied to this complication, espe- cially to the slighter of those seizures which commence as apoplexy, is that form of attack mentioned by Dr. Prichard(p. 86.) as interme- diate between apoplexy and epilepsy. In these fits, the patient falls to the ground, and lies for some time in a state of insensibility; but without any ri- gidity or convulsion of the muscular system. They are sometimes preceded by vertigo; and seem — at least, in the cases which I have seen — to be slight forms of those attacks which I have ascribed to sudden congestion of blood on the brain (see Brain, § 139.), probably with some degree of affection of the medulla oblongata. They evi- dently are connected with epilepsy, inasmuch as they are occasioned by the same kind of causes as produce it, and are often met with in persons at other times subject to epileptic or convulsive seizures; the one species of fit frequently passing into or superseding the other. They are often consequent upon disorder of the uterine functions, and upon hysterical affections; and •hey then sometimes become convulsive as the attacks subside. 42. (c) The complication of epilepsy with par- alysis may appear in the same manner as the foregoing; the latter occurring either during the advanced progress of protracted cases of the former, or almost contemporaneously with it, or even long previously to it; but I believe that paralysis is most frequently consequent upon the epileptic seizures. Of this I have seen several instances; the paralytic affection consisting of loss either of sensation, or of motion, or of both, in one limb, or in half the body; and occasionally of loss of sensation in one limb, and of loss of motion in another on the opposite side. Although this association is most common after repeated seizures, yet have I met with it after the first; the paralysis either disappearing some days or weeks afterwards, and recurring after each fit, or being from the first permanent, or ultimately be- coming so. In some cases the paroxysm follows the paralysis, and at last passes into coma or apoplexy. Dr. Ferriar (Med. Hist, and Reflect. vol. ii. p. 11.); DlPercival (Essays, Med. and Experim.vol.i.p. 148.), and Dr. Prichard (On Nerv. Dis. p. 60.), have recorded cases of this kind. Occasionally the paralytic state entirely supersedes the epileptic seizures; this latter dis- appearing, but the former being permanent. But this complication may be further associated with insanity or imbecility, or with amaurosis; and the seizure may, moreover, present a mixture of 796 EPILEPSY — Appearances after Death. epilepsy and paralysis, or a state intermediate between both, as remarked by Piso, Mead, l"i rriar, Prichard, and myself. 43.(d) Of theother complications, little beyond the mere mention is necessary.—Hysteria,chorea, catalepsy, and somnambulism, not infrequently pass into epilepsy; and the seizures are sometimes intermediate between either of these affections and this disease. In a very large proportion of these cases, the uterine functions, or the digestive organs, are more or less disordered at the same time — such disorder proving the determining cause of the aggravated or epileptic character of the attacks. — Epilepsy may be also associated with hypochondriasis and melancholy, thedigestive and biliary organs being generally remarkably disordered in these cases. I have likewise seen it alternate with delirium tremens, or this latter affection follow a regular paroxysm of epilepsy; and the same case, which has been thus associat- ed, may ultimately pass, after a recurrence of the fits, into permanent mania or paralysis.* 44. V. Appearances after Death. — It has already been stated (§22.), that epileptic seizures may be connected with any of the or- ganic lesions described in the articles Brain, and Cranium; but they sometimes are independent of any change cognisable to the senses. Appear- ances, however, vary much according as death has taken place in the fit or in the interval, and as the disease has been simple or complicated. 45. A.—(a) In the simple states ofthe disease (§ 26.), when the patient has died of some other malady unconnected with epilepsy, and has evinc- ed no disorder of the locomotive and intellectual powers, either immediately after the fits, or during the intervals, little or no alteration can be detect- ed in the nervous system. Occasionally, small tubercles,increased vascularity in parts, or bony deposits, and various other very slight changes, which are frequently observed without having produced any disorder of the nervous functions, are detected; but these may be viewed as coinci- dences, rather than as lesions connected with this disease. — (6) When the patient dies during the attack of simple epilepsy, the substance and mem- branes of the brain and cerebellum are generally loaded and injected with dark blood, as observed in persons who have died from hanging or as- phyxy. But this change is no further connected with epilepsy than being contingent on the form and mode of death in the paroxysm. 46. B.—(a) In the complicated states (§38.), especially in that with mental disorder, lesions of great diversity are generally found ; consisting chiefly of induration of the medullary substance of the brain, frequently with more or less in- jection, and of considerable dilatation of the blood-vessels. In some cases accompanying the dilatation of the vessels, the medullary structure is soft, flabby, or flaccid. These alterations are *I was, whilst writing this, called to a man reduced in circumstances, from habits of intoxication; and who had experienced two or more a;tacks of delirium tremens. He was seized with an epileptic fit, brought on by the fear of being run over by a carriage near his own hous". He had a return of the delirium tremens upon recovery from the par oxysm. A gentleman, given to occasional intoxication, is at this moment under the care of Mr. Carter and myself. He has had regular attacks of epilepsy, followed by delirium trem ns. The last paroxysm has not been followed by this affection, but by threatened paralysis. generally limited in extent; but are met with in all the white portions of the encephalon. In ad- dition to these, the grey substance often presents inequalities of surface, alterations of colour and consistence, and vascular injections — the usual results of chronic inflammation; and, in some in- stances, adhesions of a portion of the cortical sur- face to the membranes, or accumulations of serum in the ventricles. Greding states, that of sixteen maniacal epileptics, the lateral ventricles of thirteen were filled with serum ; and the brain softer than natural in nearly the same proportion of cases. In rarer instances, partial or general atrophy or hypertrophy of the brain is met with. — (b) In epilepsy complicated with apoplexy, either ex- treme injection of the vessels with dark blood, or the appearances presented by the different states of that disease, or great effusion of serum into the ventricles (Richter, Mills, &c), are met with. In those accompanied by paralysis, tumours and various other adventitious formations, cysts, soft- ening, extravasation of blood, abscesses, and the other lesions described in the articles Apoplexy, Brain, and Paralysis, are usually observed. 47. C. In the sympathetic states, alterations of the medulla oblongata and spinal cord, similar to those found in the encephalon, have been re- marked by Morgagni, Harles,Frank, Gre- ding, and others. Water in the pericardium; enlargement and dilatation of the cavities; thin- ning and softening of the walls of the heart; and diminution of its entire bulk; have been noticed by Lieutaud, Greding, and Pew.—Hepatisation and congestion of the lungs, and purulent collec- tions in them, have been recorded by Bonet, Baader, and the writers just mentioned. — En- largement and other lesions ofthe liver have been observed by Prichard, Dr. Cheyne, and my- self.—In a case of abscess ofthe liver, lately under my care, and seen also by Mr. Copland Hutch- ison, an epileptic fit occurred at a time when the diaphragm was much affected. — Calculi in the kidneys have been met with by Bartholin, La Motte, and Brendel; and disease of its secret- ing structure, by Dr. Bright. 48. D. The Wenzei.s, in their numerous dis- sections, directed attention to the state of the pituitary and pineal glands ; but the result of their researches, until the mistake was pointed out by Dr. Sims (Lond. Med. Gaz. vol. vii. p. 374.), was referred to the cerebellum, by nearly all subsequent writers, excepting Esq,ui- rol. These able pathologists found the pitui- tary gland and infundibulum variously altered in colour, consistence, size, and structure, in nearly all the cases of epilepsy they examined; and the spinous processes of the os frontis, the crista-galli of the ethmoid, and the clynoid pro- cesses of the sphenoid bone, more or less pro- minent, or otherwise changed in position and shape, in most of them. The pineal gland was also more or less altered in colour, and softer than usual, in the larger proportion of cases. — Caries, thickening, internal exostoses, spiculi, malformations, and malpositions, of the bones at the base of the skull, with various changes of the membranes, were met with in several instances. In fifteen cases out of twenty, the cerebrum and cerebellum were quite sound. Alterations in the sphenoid bone and pituitary gland have been found likewise by Greding, Neumann, Sims, and EPILEPSY —Nature of. 797 myself. Greding has also observed changes of the pineal gland, and fibrinous concretions ad- hering to the inner surface ofthe sinuses,— appear- ances likewise noticed by Wagner and myself. Nearly all the lesions described in § 29. et seq of the article on the Brain and its Membranes have been occasionally detected, but not so frequently as the foregoing, nor so often in this as in some other diseases of the nervous system, as insanity, paralysis, &c. Indeed, the most important ma- ladies seated in this system, as somnambulism, chorea, hysteria catalepsy, ecstasy, convulsions, epilepsy, mania, apoplexy, and paralysis, are merely modifications, with exaltations of grade, of nearly the same pathological conditions. 49. VI. Nature of Efilepsy.— There are certain circumstances connected with the patho- logy of epilepsy, fully ascertained, and which should be kept in recollection in our speculations as to its nature and treatment:— 1st. That it may remotely depend upon inanition, losses of blood, or a deficient quantity or quality of this fluid.— 2d. That it may be owing to a totally opposite state as respects either the system generally, or the brain especially.— 3d. That it seldom occurs in persons whose digestive, assimilating, and cir- culating organs perform their functions regularly — 4th. That, in the simple and early disease, it is not dependent upon any lesion cognisable by our unassisted senses, unless such lesion be seated in the medulla oblongata or pituitary and pineal glands,— parts not yet sufficiently examined in this malady, and which may be dangerously affected without manifesting any material change. — 5th. That the appearances found in old or complicated cases are to be referred rather to the repeated derangements the circulation of the brain has suffered in the paroxysm, and to the nature of the associated disease, than to the lesions detected in fatal cases; such lesions, how- ever, when induced in the course of other dis- orders, being occasionally exciting or concur- rent causes of the epileptic attacks.— 6th. That general congestion of the encephalic vessels evidently exists in the second or convulsive stage of the fit; but it is not so manifest that this state is present from the commencement of the seizure, as cases have presented, at this period, symptoms of a very opposite condition.— 7th. This con- gestion is only a passing phenomenon, evidently caused by interruption to the respiratory actions, impeded circulation through the heart, and to the spasmodic action of the muscular system ; and is not the cause of the seizure, the principal phenomena of the fit even ceasing at the very moment when the congestion is at its height.— 8th. The paroxysms of epilepsy cannot, therefore, be imputed to the congestion, which is evidently an advanced or consecutive phenomenon pro- duced as now stated; but must be referred to the parts on which sensibility depends, and which actuate the respiratory and muscular organs. 50. Although these positions seem not to admit of being controverted, yet there are other points necessary to a knowledge of the nature of the disease that still require to be ascertained:— (a) What are the states ofthe heart's action, and of the circulation, particularly in the head, just be- fore and at the time of seizure ?— (6) Is the sus- pension ofthe heart's action sometimes observed at this time, owing to a spasmodic contraction of 67M some continuance; or to sudden loss of power; or to an interruption of the return of blood to either side of the heart ? It is obvious that, until these and other points are fully ascertained, no satisfactory conclusion can be come to raspecting the nature of the disease. Numerous opinions have been offered, but very few of them require any notice. The ancients supposed that the dis- order is caused by a pituitous humour in the ven- tricles of the brain, the symptoms arising from an effort of nature to relieve herself from it. BoERHAAVEand Van Swieten- imputed it to a morbid action of the brain exciting the nerves of motion, and obscuring those of sensation. Dr. Cullen considered that it may proceed in some cases from too great cxcilement of the brain, and in others from collapse. Numerous modern writers have referred it to a change in the structure of parts within the cranium. But opposed to this opinion, are the facts, that in the simple disease lesions are seldom observed; and that, when ob- served in either the simple or complicated states, they are not uniform, or even of the same kind, and are as frequently seen in other diseases of the brain, unattended by convulsions, as in epilepsy. Dr. J. Johnson has remarked that the immediate cause ofthe attack seems to be a temporary local turgescence of the cerebral vessels, determined by a temporary super-excitement of the nervous structure of the parts thus affected. This opin- ion is very generally adopted in connection with the inferences, that local turgescence or plethora causes pressure; and that pressure, when general, produces apoplexy; when partial, paralysis; and when slight, epileptic convulsions,— phenomena which, doubtless, frequently arise from these con- ditions, but not from them alone, but likewise from others; symptoms of pressure being very often altogether wanting at the commencement of the fit.—Mr. Mans ford, proceeding on the supposition that the nervous and electro-motive fluids are identical, has contended that the brain is constantly generating them, and that, in health, they are controlled by the will, in opposition to their natural tendencies; their formation, reten- tion, and discharge thereby being duly regulated; but, when weakened by disease, this control is irregularly or imperfectly exercised, and their accumulation is favoured, until it reaches its maxi- mum, when it explodes in an epileptic seizure. It is obvious that this opinion is entirely founded on a postulatum —the indentity of nervous influ- ence with the electricities—to which few will sub- scribe. Sauvages had long ago ascertained by experiment that the hemispheres of the denuded brain may be punctured without exciting sensibi- lity ; but that, as soon as the instrument reaches the origin ofthe nerves, or the medulla oblongata, epileptic convulsions are produced (Nosol. Me- thod, vol. i. p. 782.), and hence concluded, that whatever especially affects those parts, may induce the disease. The opinion has been adopted by several pathologists, and probably approximates as nearly to the truth as can be expected in the present state of our knowledge.— The researches of the Wenzels have led them to imagine that the proximate cause is to be referred chiefly to the pituitary and pineal glands, especially the former; and it is not improbable that impairment or other disorder of the function I have attributed at another place to these parts (see Apoplexy, 77 798 EPILEPSY- § 103, 104.), may be concerned in some way or other in deranging the circulation of the encepha- lic organs, and in predisposing, or giving rise, to the disease. Dr. Reid, insisting on the suspen- sion ofthe heart's action at the commencement of the fit, and on the tetanic rigidity of the muscles in the first stage of it, has referred these changes to "Irritation or accumulation of blood in the spinal nervous mass," particularly the cervical portion. Dr. Shearman has contended, with much jus- tice, that simple epilepsy often owes its origin to deficiency of nervous energy, or irregular distribu- tion of it, independently of vascular excitement or any primary disorder of the circulation. 51. It is unnecessary to offer any further opin- ion of the foregoing views. From a survey of the predisposing and exciting causes, and of their mode of operation, as well as of the connection frequently subsisting between other diseases and this, it seems probable, that changes in the organ- ic nervous influence of the encephalon, or altera- tions of structure of any part within .the cranium, may so affect those parts at the base ofthe brain, connected with the origin of the nerves, especially the medulla oblongata, as to suppress sensibility, derange the functions of respiration and circu- lation, and occasion inordinate action of the muscles, under the influence of the cerebro-spi- nal axis — in short, to disorder especially the functions depending upon these parts, in the manner constituting the disease. It may be urged that, if this affection arise from irritation or any other change in the parts now named, wherefore is it paroxysmal, or of occasional occurrence and short continuance ? To this I can only answer, that nervous excitement, not depending upon or kept up by inflammatory action, is usually mani- fested in this form; that any other than functional affection of the parts about the origin of the nerves of respiration cannot produce the disease, as any remarkable change of structure of these parts is quickly followed by death ; and that, presuming the change therefore to be functional, or at most very slightly structural, the successive phenomena constituting the different stages of the paroxysm most probably remove for a longer or shorter time, according to the duration of the interval, the particular condition which excited th'e attack. According to this view, irritations or other alterations of function or structure in remote but related organs or structures may affect the medulla oblongata or adjoining parts, so as to induce a paroxysm of the disease, especially in persons predisposed to disorder of these parts, the predisposition arising from the state of organic nervous influence and of circulation within the head. In such cases, the irritation is propagated by nervous connections to the situation referred to, the chief phenomena of the seizure being one ofthe numerous forms of morbid action depend- ing upou reflex sympathy.* * The aura epileptica is also, in many cases, nothing else than a manifestation of this kind of sympathy—the irritation of some internal part affecting some portion of the encepha- lic organs, the affection being reflected in the course of some nerve belonging to the cerebro-spinal system. In cases where this sensation may depend upon some change in the part where it originates, the paroxysm is still more evidently an expression of reflex sympathy. The reader may refer to my remarks on the Sympathies, in the first and second edi- tions of my notes to M. RicheraNI 's Physiology (pub 1824 and 1829), where he will find them divided into the direct and reflex—" direct sympathy," sympathy depending -Diagnosis. 52. VII. Diagnosis.—The intimate relation subsisting between the diseases of the nervous system just alluded to, might lead to the inference that the diagnosis of epilepsy would be sometimes a matter of difficulty. But in the regular and un- complicated form ofthe disease, no difficulty will be experienced. It is only when insensibility precedes the convulsions; or when there are no convulsions, or merely slight or partial convul- sions; or when there is violent delirium in the paroxysm; or when there are convulsions with some degree of consciousness; or when one half the body is only affected — all which modifica- tions may occasionally present themselves in both the simple and associated forms ofthe disease;— that the practitioner can doubt as to the exact nature of the attack. The intermediate seizures also between epilepsy and apoplexy (§41.), which frequently attack aged persons, and are, as respects the course of the affection, merely a variety of epilepsy, without the convulsions — the Leipothymia of Sauvages—may also be mistaken, especially for apoplexy, or for syncope; but, by attending to the history ofthe disease, in all its forms, and to the state of the pulse in the fit, its nature will become apparent. When the paroxysms exhibit the regular course described above, as they usually do, there can be no diffi- culty in the diagnosis. 53. (a) li the fit be complicated with apoplexy, it may be mistaken for the simple form of that malady; but convulsions will sufficiently show the mixed nature of the attack. In the inter- mediate states (§ 41.), or the paroxysms without convulsions, greater difficulty will be experienced. The nature ofthe seizure will, however, be evin- ced upon tickling the soles; for, if it be epileptic, no sensibility will be evinced, particularly in the first and second stages ofthe fit; whereas, in apo- plexy, the patient draws away his feet, unless there be paralysis, but still one foot will retain its sensi- bility. Besides, this form of fit is seldom above half an hour, or an hour in duration, unless it be aggravated by improper treatment.—(b) Hysteria may be mistaken for epilepsy, particularly when the paroxysms of the former are severe; but the borborygmi and globus hystericus, the discharge of limpid urine, followed by laughing, crying, sobbing, &c. will indicate their nature. More- over sensibility is only obscured, but never alto- gether lost, in hysteria, until it has assumed the epileptic character; and the convulsions come on first, even when the insensibility is greatest; the restoration of sensibility being often followed by a renewal of the convulsions, the patient at last recovering without any sopor, and with little or no fatigue. — (c) The convulsions of children are often confounded with epilepsy, although both affections are very distinct. The former are more upon the organic nervous functions; " reflex sympathy,' upon the cerebro-spinal. See, also, a paper, in the Philo- sophical Transactions for 1833, on the latter class of sym- pathies—the reflex, which the author has dignified by the name of " reflex function." The reader will then see in what this neai " reflex function," of the nervous system dif- fers from the old l; reflex sympathy" of the nervous system ; or whether it differs at all; also whether or not the pheno inena usually designated by the term sympathetic are more correctly named by substituting for it the word function: function, in physiology, being the office any part especially perforins, and not such phenomena as only accidentally or occasionally depend upon it. EPILEPSY — Prognosis—Treatment. 799 continued or recurrent; are more irregular in their course; and are accompanied with more or less fever, loss of appetite, and often with thirst: whilst the latter is less frequent, more periodic, and attended by much less disorder of the diges- tive, circulating, and assimilating functions ; the one being an acute, the other a chronic, malady. — (d) In fine, epileptic seizures may be readily distinguished from all others by — 1st, their com- mencing with a scream, and sudden and complete loss of sensibility; 2d, the spastic rigidity of the affected muscles in the first stage; 3d, the convul- sions being more tetanic than clonic, unless iu severe cases complicated with apoplexy; 4th, the foaming at the mouth, distortion of the features, and lividity of the countenance; 5th, the priapism and unconscious discharges; 6th, the injury sus- tained by the tongue; and 7th, the consequent sopor, or mental aberration. The diagnosis of real from feigned epilepsy is considered in the article on Feigning Disease. 54. VIII. Prognosis.—An opinion ofthe dis- ease should have reference—1st, to the recurrence ofthe paroxysms; 2d, to their severity, duration, and the danger to be apprehended; and, 3d, to the nature of the disorder complicated with them. Of epilepsy generally it may be said, even when the simple form, and not very frequent recurrence, of the fits indicate no immediate danger, that few disorders are more intractable, or more liable to contingent complications of a very serious kind. The danger varies materially in the different varieties and states oi the disease, and increases as the fits return more frequently, as they become more severe or of longer duration, and as addi- tional disorder of the nervous system associates itself with them. — (a) In the simple forms, the cerebral symptoms, preceding and following the fits, are the chief guides in forming a prognosis; but what is known of the causes must also be taken into account. The presence of intense pain, vigilance, delirium, mania, amaurosis, para- lytic symptoms, &c, either before or after the seizure, indicate organic lesions of the brain, and an unfavourable form of the disease, usually pass- ing into some one of the complications described above. In cases of this kind, considerable danger is to be apprehended from the paroxysm, espe- cially when there is evident plethora. Hereditary predisposition, severe injuries ofthe head, and the scrofulous diathesis, although not necessarily indi- cating immediate danger, are also very unfavour- able circumstances. 55. (b) The sympathetic states, or those associ- ated with or arising from disease in related organs, tire generally less dangerous than the cerebral varieties. Of these forms, the most serious are the spinal and cardiac; and the least so, the uterine, enteric, and stomachic or dyspeptic, but much will depend upon the amount of disorder in the respective organs, and the habits of the patient, particularly as to indulgence of the appe- tites. When these are under due control, the latter three varieties often terminate favourably. The uterine variety sometimes disappears after marriage; but if an attack occurs in the puerperal states, it is attended by much danger. 56. (c) The complicated varieties present few j chances of complete recovery, especially the paralytic and the insane. When, however, the paralytic symptoms are slight, or pass away soon after the fit, recovery should not be despaired of; and the same may be said of the form attended by temporary delirium, or by delirium tremens, or by temporary mania, or intermitting insanity. M. Eso_uirol states, that epilepsy complicated with continued insanity is never cured. I have seen complete recovery from the apoplectic vari- ety ; but this is a complication also of great, and often immediate, danger. The intermediate form is much less dangerous. 57. (d) The fits usually recur most frequently in the cerebral and complicated forms; and next in the spinal and cardiac. They are most rare in the uterine, and the nephritic, and in the gastric and hepatic. Dr. Cheyne thinks that the dis- ease is most inveterate, when it is accompanied with chronic cutaneous affections. Addiction to masturbation aggravates and prolongs it, and often causes it to pass into the paralytic and maniacal or insane complications; but, when it has arisen from this most baneful and disgusting practice, and the patient has had resolution enough entirely to relinquish it, a complete cure will often be ac- complished. Epileptic seizures from the metasta- sis of gout or rheumatism, or in persons of the gouty or rheumatic diathesis, may not return, if these diseases fix themselves in the extremities. When the fits arise from the syphilitic infection, a mercurial course will generally remove them per- manently. M. Cullerier has recorded several instances of this. 58. LX. Treatment.—i. Ofthe Paroxysm. — The intention is to shorten the fit, or render it less severe: but this is not easily accomplished; and the means usually recommended for the pur- pose, if inappropriately used, may have a very opposite effect; and either render the next seizure more severe, and the interval shorter; or convert what would have been a simple, and by no means serious, paroxysm into a recurring and prolonged seizure, followed by various unfavourable symp- toms.— Bleeding nas been advised in the par- oxysm ; but, unless in the epilectic convulsions of the puerperal states, or when the fits are attended by very marked plethora, or cerebral congestion, or in a first attack, especially when consequent upon the suppression of some san- guineous evacuation, it should be deferred. Be- sides, it cannot easily be performed in the con- vulsive stage of the paroxysm, at which time it is most appropriate. In the just mentioned excepted circumstances, however, I have directed it with great aavantage. But in the soporose period of the fit, it should not be resorted to, unless apo- plectic symptoms be present. I have seen it, at this stage, cause a return of the paroxysm as soon as sensibility had been partially restored.* * A gentleman, residing near Portman Square, had been under my care, in the spring of 1833, for articular rheuma- tism. He soon recovered, and went out of town. Towards the close of the year, whilst in Scotland, he had an epileptic attack; and was blooded in the arm, and cupped soon after- wards. This was the -econd seizure, the first having occurred two or three years before. He returned to town immediately after this second attack; and, when I saw him, there appeared no occasion for further vascular depletion: a course of alter- atives and stomachic purgatives was therefore directed. Three or four days afterwards, he had a third seizure, and was brought home in the soporose stage of the fit. I dd not see him until about two hours afterwards; and then a phvsician, who had been called in whilst I was sent for, had tiad him cupped largely ! But. soon after the depletion, and as > n- sibihty was returning, the paroxysm recurred. The obvious 800 EPILEPSY —Treatment. — The cold affusion on the head and occiput is sometimes useful, particularly where there is much heat of the head, and when the disease has been consequent upon or connected with hysteria, or associated with uterine disorder; but in other circumstances I have not seen so much advantage from it as I had anticipated. Brera (Giorn. di Med. Prat. t. iii. c. 3.) however, speaks of it very favourably. It requires, however, discrimination as to the time and manner of employing it; for it may be even injurious, if resorted to in the sopo- rose stage, or continued too long, especially when the head is cool, and the pulsation of the carotids is weak: in these, the tepid or warm affusion is much more appropriate. — Antispasmodic and purgative enemata are, upon the whole, as safe and efficacious means as can be employed in the fit. When there is but little determination to the head, the assafcetida injection, with or without a small quantity of camphor, and some castor oil, may be preferred. But when this symptom is present, the terebinthinated enema (F. 15Q-) is more efficient. In some cases it will be ad- visable to combine these substances, or to add others. 59. Under every circumstance, all ligatures and cinctures should be instantly removed; and the patient placed in bed, in a large and very airy apartment, with the head and shoulders much elevated. A cork or wedge-shaped piece of soft wood ought to be introduced between the teeth, and the struggles gently but not forcibly restrained, so as to prevent the patient from in- juring himself by their violence. Certain popular remedies have been noticed by writers. Dr. F. Hawkins thinks that filling the patient's mouth with common salt is not without use ; and J. Frank entertains a similar opinion of placing a piece of cold metal in the hands. I have seen apparent benefit from a similar application to the nape of the neck and occiput; and probably ice, Or the cold affusion, in this situation, would be course in this case was, to have caused th» patient to be re-roved to bed, and to have stated that nothing further was requisite in that stage of the fit until the patient had partly slept off the exhaustion ; when the physician in attendance would pursue that course which his knowledge of the ante- cedent disorders and state of the patient w< uld warrant. Whilst this was passing through the press, a man of middle size apparently about forty, consulted me; and staled that he had been seized with the first paroxysm of the disease immediately post co'itum quinquies repetitum duabus cum puellis inter horas perpaucas; that he had been blooded to ab ut a pint soon aflerw rds, and experienced a still more severe fit about a month after the first; that the third seizure occurred about a fortnight after the second during which he fell down and cut his Tiead, the cut part having nled a pint at least that his usual medical attendant up n arriving soon after the termination of this fit, bled him largely from the arm ; but that, as soon as ihe vein was closed, the fit recur red; and that, riuring the struggles, the vein broke out, and the blood was allowed to flow until two or three pints were taken in addition to the quantities lost just before. The per- son who accompanied him to my house, on account of his weak state,and who witnessed the paroxysms,stated (hat this last was most severe ; and that the fit which recurred during the depleti n and which was attempted to he put a stop to by continuing the abstraction of blood until a very unusual quantity was lost (about five pints in all) was remarkably prolonged and violent. The patient is now pale and weak, with a waxy appearance of the surface; completely exh ust- ed, physically and mentally ; and constantly dreading a recurrence of the paroxysms. This case furnishes a very remarkable instance, not only of the failure of large blood- letting in arrest ng or shortening the fits but also of its influ- ence in rendering them more frequent and violent, when injudicfcusly prescribed. equally useful. Upon the whole, excepting the precautions recommended above, it will be ns well to adopt the advice of Celsus, and to do but little in the paroxysm, unless under the cir- cumstances now stated. Where the fits are mod- erate and uncomplicated, and especially when the practitioner is either in doubt, or insufficiently informed as to the state or variety of the disease, this is certainly the safest plan; for in the simple forms of epilepsy, I have seen more harm than advantage from the " nimia diligentia medici " during the paroxysm. 60. ii. Treatment in the Intervals. — Upon visiting an epileptic patient, the physician should enquire into his general health, disposition, avo- cations, habits, modes of living, and former at- tacks of this or of other diseases; and ascertain the causes of the first seizure. The information thus obtained, viewed in connection with his pre- sent state, will generally enable the physician to ascertain the following things, which are of the utmost practical importance:—(a) The existence of plethora, of asthenia, or of inanition, and the probable extent of either, in the simple, the sym- pathetic, and complicated forms of the malady; — (b) The states of the digestive, assimilating, circulating, depurative, and generative functions, and ofthe organs chiefly concerned in them — or the sympathetic forms of the disease; — (c) The existence of other disorders ofthe nervous system, and especially with reference to chronic inflam- mation, or its effects in parts within the cranium — or the complicated states; — (d) The evidence of impending or of more remote danger. Having thus analysed the case, the particular variety to which it should be referred will be determined with greater ease. Proceeding thus, in order to the due appropriation of the means of cure, the physician should direct them calmly and decided- ly, with reference to the disposition, the feelings, the weaknesses, and the irresolution of the pa- tient; and in a manner calculated to gain his con- fidence, and to inspire hope. In this, as well as in all nervous diseases, the communications of the physican should be brief, clear, and forcible, without descending to any explanation whatever, either as to the cause or intimate nature of the disease, and the operation of the remedies he recommends, or as to his reasons for adopting them in preference to others; for these are mat- ters respecting which no one but a well-educated medical man can think aright, or should even attempt to think. All endeavours to explain ab- stract matters connected with disease, and the means of removing it, to unprofessional persons, however well informed they may be, is to place ourselves at the mercy of the pragmatical objector or self-sufficient volunteer in the professed cause of humanity. That ignorant empirics are some- times apparently more successful in the cure of nervous diseases, than scientific practitioners, chiefly arises from the circumstance of the for- mer being incapable of stating their views, or assigning reasons for their procedures ; whilst the latter, as justly remarked by Dr. Cheyne, are generally very much too ready, as re- spects both their own reputation, and the con- fidence of their patients, to explain every thing. The empiric is fully convinced of the justice of the apothegm — "Omne ignotum pro magnifico,'1' — and acts conformably with it : EPILEPSY —Simple Cer the man of science is candid, and ready to impart to others the views he entertains. The silence of the one, although generally the cloak of igno- rance, imposes more on the public than the open deductions of the other, however confirmed by science and enlightened experience. 61. iii. Treatment of Simple Cerebral Epilepsy. — A. This form of the disease, depending upon deficient power, and inanition (§ 27.), being oc- casioned chiefly by exhausting discharges, vicious habits, or imperfect nutrition, obviously requires the removal of these causes, and means to in- vigorate the nervous system, and equalise the circulation, which, even when the blood is most deficient in quantity, is generally inordinately determined to particular organs, and especially to the brain, during the convulsive stage of the fit. In this and the other form (§ 63.) of the cerebral disease, the moral means just hinted at are especially required, with the regimen here- after to be described; and, whilst the mind is confirmed thereby, these intentions may be sim- ultaneously fulfilled. With this view, a light and nutritious diet, in very moderate quantity, and chiefly farinaceous, may be allowed; and the preparations of iron exhibited in conjunction with bitter tonics, or stomachic laxatives. The feet should be kept warm, and the head cool, whilst the circulation on the surface is promoted by daily shampooing, or by frictions with coarse flannels or the flesh-brush. If there be occa- sional flushes, or increased heat of the scalp, the hair should be cut close, and the head sponged night and morning, or even oftener, with a cold acetous lotion. Moxas or blisters may be applied behind the ears, and repeated from time to time, or a seton inserted in the nape of the neck. In some cases, the latter may be found too irritating or exhausting; but, even in these, it may be of service, if the rest of the treatment and regimen be sufficiently invigorating; and the digestive and assimilative functions be judiciously promoted. As amendment proceeds, the cold sponging of the scalp may be replaced by the daily use, in the morning, of the shower bath. 62. Where we have reason to suspect that the disease has been induced by venereal excesses, the subcarbonate of soda may be given with tonics, and soda water taken as a common beve- rage : but neither of these ought to be continued too long. In the scrofulous diathesis, and where we suspect organic change, Brandish's alkaline solution may be prescribed, in any of the bitter infusions; or a solution of the ioduret of iron, or of the hydriodate of potash. In a case very re- cently under my care, three grains of blue pill, with seven of the aloes and myrrh pill, were given on alternate nights, and one of the above preparations of iodine during the day, with very remarkable advantage. When the functions of the liver are impaired, as occasionally happens, small but frequent doses of the preparations of mercury, with taraxacum, taking care not to affect the mouth, will be of service. I have found them, however, often fail of improving the excretions, until tonics were also exhibited. In a case of this kind, I prescribed very small doses ofthe oxymuriate with the compound tincture of bark, and the preparations of sarsaparilla, with great benefit. Equal proportions of the nitric and muriatic acids, thrice daily, or oftener, or the bral—Treatment of. 801 addition of them to the warm foot-bath, may also be useful.—When the disease proceeds from ex- cessive sexual indulgences, late hours, and ad- diction to intoxicating liquors — a combination of causes by no means infrequently inducing it — the alkaline carbonates, or the liquor potassae with the infusion of valerian, or bitter tonics; or very small doses of camphor with the oxide of zinc, and cinchona, or the tincture of the muriate of iron in the infusion of quassia, may be employed. In this, as well as in the other varieties of the disease, when depletions and depressing agents have been carried too far, the preparations of iodine, or the extract of nux vomica, or strychnine, or other tonic and antispasmodic remedies here- after to be noticed, may be prescribed, in forms of combinations which the peculiarities of the case will suggest. 63. B. Simple cerebral epilepsy, connected with plethora or exdted action in the head, is the most common form of this variety, in this country; and requires, according to the apparent degree of either of these pathological,states, bloodletting, general or local, or both; and, subsequently, the affusion of cold water on, or cold sponging, the head, or the shower bath; derivatives, particu- larly setons, moxas, or issues, or blisters behind both ears, kept open some time, or often repeated; and purgatives every second or third night, with low diet, and total abstinence from all spirituous and fermented liquors. Unless plethora or vas- cular action be very considerable, local blood- letting once a month, in moderate or small quan- tity, is preferable to large depletions; and, if the fits recur monthly, the patient may be cupped just before the new or full moon, according to the period at which the fits recur. Dry cupping over the nucha and between the shoulders may likewise be practised once or twice, of" even oftener, between the bleedings, as judiciously advised by Dr. Cheyne. An issue or seton near the nape of the neck, or an open blister, is more serviceable in this than in the preceding form of cerebral epilepsy. Where there is mani- fest determination to, or increased vascular ac- tion in, the brain, antimonials, and especially James's powders, are often beneficial. Dr. Cheyne (Dub. Hosp. Rep. vol. i. p. 315.) re- commends this powder to be taken at bedtime, commencing with two or three grains, and increas- ing the dose by half a grain each night, until a sensible effect is produced on the skin, stomach, or bowels. If it occasion sickness, the dose should be diminished one grain on the following night. He states that, by adding a few grains of rhubarb to it, a larger quantity of the James's powder will be borne by the stomach than could other- wise be taken. If it produce diaphoresis, the same dose may be continued for three weeks, and then it should be reduced half a grain each night; the course of this medicine thus usually extend- ing to six weeks. In this manner the dose may be increased to fifteen or twenty grains, and con- tinued for some weeks, without offending the sto- mach. When we suspect the existence of a state of chronic inflammatory action, the antimonial liniment (F. 301.) or ointment (F. 749.), may be rubbed along the spine, or over the nape of the neck and occiput; the latter application being continued until a copious eruption of pustules is procured, which should be kept out for some time. 803 EPILEPSY —Sympathetic —Treatment of. 64. Although cerebral or simple epilepsy fre- quently appears connected with one or other of the states of vascular fulness and action above specified, yet cases will also often occur in which the practitioner will be at a loss to determine the presence of either; the disease being dependent upon deficient nervous power, with irregular cir- culation or distribution of blood, rather than upon any deficiency or excess of this fluid. In these cases, the vital nervous system is primarily and chiefly in fault; congestion or irritation possibly also existing in the medulla oblongata or adjoin- ing parts of the encephalon. But little advantage can be expected in such from depletions only, especially when pushed far, as they will increase these morbid states, and even favour determination of blood to the head. I believe that most advan- tage will accrue from such remedies as will pro- mote an equable and free action of all the excret- ing organs, and impart tone to the nervous system. Light diet and very moderate use of animal food; total abstinence from fermented and spirituous liquors; careful avoidance of the predisposing and exciting causes, and particularly of those in which the case originated; regular exercise in the open air, taken often, and short of fatigue; travelling, or frequent change of air; a due regulation or moderation of all the passions and appetites; the daily use of the shower bath: external irritation or derivation; and anti-epileptic tonics and anti- spasmodics; or moderate local depletions, or dry cupping, or both, as circumstances may indicate; are the most rational resources. When the case evinces an inclination to one or other of the states above considered, the treatment pointed out with reference to it should be enforced to an extent co-ordinate with the amount of such disorder. If there be any tendency to plethora or excited action, animal food should be altogether relin- quished,— a measure advised also by Fother- gill, Heberden, Frank, Abercrombie, and Cheyne. 65. iv. Treatment ofthe Sympathetic Varieties. — A. From Disease of the Spinal Cord or Nerves (§ 30, 31.).—This variety will necessarily require either vascular depletions, or tonics, or even both, according to the degree in which ple- thora, increased action, or deficient power, is in- ferred to be present. — (a) Where increased ful- ness or action exists, cupping, the application of leeches, and dry-cupping in the course ofthe spine, the insertion of setons or issues a little below the seat of pain, frictions with the mercurial and com- pound camphor liniments, or the repeated appli- cation of moxas, are the most efficient means, aided by purgatives, the usual antiphlogistic rem- edies, and by rest. — (6) Increased vascular ac- tion in the spinal cord, or its surrounding parts, is, however, often associated with deficient power, and sometimes even with inanition. In such cases, whilst moderate local depletion, dry cup- ping, external derivation, &c. are resorted to, the more antispasmodic tonics, as valerian, myrrh, castor, &c, and even the preparations of iron, cinchona, camphor, ammonia, &c, should be prescribed. —(c) This state of disease is not in- frequently induced by masturbation. In this case, cold aspersion ofthe genitals, night and morning; sponging the spine with cold salt water, or with vinegar and water ; or the effusion or aspersion of these along the back; and the internal use of the muriated tincture of iron, or of the carbonate of iron with soda, or of Bran dish's alkaline solution in tonic infusions; will prove of the greatest benefit. Due regulation of all the se- cretions and excretions; early rising; and, as the strength increases, a shower bath every morning; will also be powerful adjuvants. When cold sponging, &c. are not resorted to, tonic plasters (F. 111. 117, 118.) may be applied along the spine. — (d) If pressure from the effusion of lymph, or serum, or from the thickening of some portion of the sheath of the cord, be inferred after a careful examination, the preparations of iodine may be tried both internally and externally, par- ticularly the hydriodate of potash, or the ioduret of mercury; or the linimentum hydrargyri and the linimentum terebinthinae may be rubbed along the spine night and morning. —(e) If the fits be preceded by an aura, a ligature should be in- stantly applied above the place at which it com- mences, if this be practicable; or a seton or issue inserted in the part, and kept freely discharging; or a blister applied before the expected return of the paroxysm, and either preserved open, or often repeated.—(/) Sometimes this variety is con- nected with uterine irritation or disorder; it being almost impossible to determine whether the spinal or the uterine affection is primary, or which of them is most instrumental in causing the epileptic seizures. Cases of this kind are met with chiefly in large or manufacturing towns, and in females who have become addicted to sexual excitement; and appear to me to be most benefited by coun- ter-irritation in the course of the spine; by the application of an antispasmodic liniment (F. 297. 311.) in this situation; and by the alkaline carbo- nates, or Brandish's solution with hyoscyamus, in tonic infusions or decoctions. Subsequently, the remedies enumerated above (c) may be pre- scribed. 66. B. With especial Disorder of the Heart or Lungs (§ 32.).—;It is by no means easy to determine what is the most appropriate and suc- cessful treatment in these states of the disease. Local depletions, antispasmodic tonics, or chaly- beates, according as the case may present excess or deficiency of blood, aided by purgatives or lax- atives, and regulated diet, are generally required. External derivation, chiefly by means of one or two setons or issues, should not be omitted. It has been supposed that the circumstances espe- cially indicating the propriety of resorting to setons or issues, contra-indicate the exhibition of tonics. But such is certainly not generally, nor even fre- quently, the case in this disease. I believe that, in many instances in which these external means fail of affording relief, the failure has been partly owing to their having been employed, either at a time when the system has been too far reduced by depletions; or in conjunction with those and other depressing agents, in cases wherein such treatment was inappropriate, or carried too far. Where the function, or even the organisation, of the heart is affected in epilepsy, it will be found that greater benefit will accrue from a ju- dicious exhibition of tonics and antispasmodics, aided by external derivation, than from other remedies. In many cases, the disorder near the centre of the circulation depends either upon de- ficient or irregularly distributed nervous power, or upon some affection of the medulla oblongata, EPILEPSY — Sympathetic—Treatment of. 803 and is merely a varied manifestation of the prima- ry form of the disease. In these, the treatment already advised for that form, according to the states of vascular fulness and action, will be ap- propriate. Where signs of pulmonary congestion or inflammation appear after repeated seizures, vascular depletions, external derivation, and low diet, must be chiefly depended upon. When the fits are preceded by a feeling or any other symp- tom of cardiac disturbance, an antispasmodic med- icine should be in readiness for the patient to resort to. The following have been recommended; and either of them, or F. 423. or 424. may be taken, in any of the forms of the disease, when premo- nition of the fit is felt. No. 210. R Aquae Amnion. Sub-carbon, gj.; Tinct Succini ^ iij. ; Tinct. Castorei, Tinct. Assaefoetidae, aa Jvjss. Capiat aeger cochleare unum minimum, vel duo, in aquae cyatho. (De Haen.) No. 211. R Fol. Recent. Lauri-Cerasi 5T'J-> tere cum Sacchari Albi 3xiv.; Pulv. Fol. Aurantii %). ; Syrup. Rosarum et Syrup. Violar. aa %\y Fiat Electuarium, cujus capiat cochleare unum medium ante paroxysmi ac- cessionem. (Van Mons.) No. 212. R Spirit. Ammonias Succinati 3''j-> Tinct. Castorei, Tinct. Valerianae, aa 5'jss- j Mist. Camphorae g vij. M. Capiat coch. ij. vel iij. magna, adveniente paroxysmo. 67. C. With Disorder ofthe Digestive Organs. —(a) In the gastric association, it may often be requisite to commence with an emetic, consisting chiefly of the sulphate of zinc. But the frequent repetition of it is very rarely of the least advan- tage. Although the appetite is often ravenous, yet digestion is slow and imperfect, and needs the aid of tonics associated with laxatives. The com- pound galbanum pill may be given through the day, conjoined with equal quantities of inspissated ox-gall and Castile soap, or with the extract of gentian and quinine; and, when the bowels are sluggish, three or four grains of the gall may be taken on alternate nights with an equal quantity of aloes. If the biliary secretion be deficient, a full dose of calomel once a week, followed by a purgative draught (F. 181, 182.), will be requi- site. If there be deficient action, or fulness, ofthe vascular system, or general asthenia, the mistura ferri composita, or the mistura ferri aromatica (Dublin Pharmacop.), may be exhibited; or the sulphate of iron, or of zinc, or of copper, or of quinine, may be prescribed with some tonic or antispasmodic extract, or with the compound gal- banum pill. In cases evincing great depression of nervous power, with deficient tone of the vas- cular and muscular systems, these latter remedies, or the ammoniaret of copper, the extract of nux vomica, or strychnine, or the nitrate of silver, may also be tried, and in similar forms of pre- scription. It is in this variety that travelling, and change of air, of domicile, or of habits, as advised by De Haen, is most likely to be of service, as Dr. Cheyne remarks. In many cases, it will be necessary to assist the digestive organs, either shortly before, at the time of, or soon after, a full meal. With this view, the aloes and myrrh pill, or aloes with mastich, or with the addition of capsicum, has been generally recommended.— Either of the digestive pills in the Appendix (F. 558. et seq.) may be directed in this manner. The ox-gall with extract of gentian, or of hop, and a grain or two of aloes, is the most beneficial; a small portion of the aloes acting fully on the bowels, when combined with these bitter tonics, or with the sulphate of quinine. These will seldom or never fail of preserving the bowels very freely open; but if irritation in the rectum be ex- cited by them, they may be relinquished for a time, and injections substituted; or they may be prescribed, in a more purgative form, every se- cond or third night. 68. (b) Cases manifesting hepatic disorder (§34.) should be treated with reference to the nature of that disorder. If symptoms of excited action be present, general or local depletions,antimonials and cooling diaphoretics, and a seton or issue near the region of the liver, will be necessary. If there be enlargement, chronic obstruction, torpor, or accu- mulation of bile in the ducts, deobstruent purga- tives, especially the preparations of mercury, the taraxacum in large doses,and subsequently a course of alteratives (see especially F. 503—511.); the repeated application of blisters over the hypoehon- drium; and the dilute nitro-muriatic acid, internally or externally, or both; will be productive of more or less benefit. As, in these cases, the functions of both the stomach and intestines are also impaired, these means should be conjoined with so much of the treatment directed with reference to disorder of these organs (§ 67. 69.) as the peculiarities of the case may warrant. 69. (c) Epilepsy from worms or other disor- ders of the intestines (§35.) should at once be treated by the purgative anthelmintics; for, even where no worms may exist, these medicines fre- quently remove morbid matters which have accu- mulated in the prima via in this variety. Having expelled these sources of irritation, antispasmodic tonics—especially valerian, assafcetida, camphor, galbanum, the preparations of iron, &c.—will generally be of great service, in preventing both a recurrence of the paroxysms and the regeneration of worms. It is in this variety that an occasional full dose of the oil of turpentine, either with cas- tor oil, or followed, in two or three hours, by this or some other purgative, is most beneficial. A full dose of calomel should also sometimes precede the exhibition ofthe turpentine; and their action may be further assisted by enemata with equal quanti- ties of these oils. When the symptoms described towards the conclusion of paragraph 35. are pre- sent, purgatives and purgative enemata every se- cond and third day; and tonics or chalybeates, with warm cardiacs and anti-spasmodics, should be prescribed for a considerable period. Frictions ofthe surface, particularly ofthe abdomen, loins, and thighs, ought also to be employed daily, occa- sionally aided by warm embrocations or liniments. Subsequently, the shower bath may be directed, and steadily persevered in, with such other ofthe remedies already recommended as the circumstan- ces of the case may require. Where associated disorder of the spleen, pancreas, or mesenteric glands is present (§36.), purgatives, deobstruents, and tonics, variously combined, and the prepara- tions of iodine, with external derivation, are chiefly to be relied upon. In this variety, the following stomachic purgatives, taken alternately, at bed- time, will frequently be very serviceable:— No. 213. R Pilul. Hydrarg. (vel Hydrarg. cum Creta), Pit. Galban. Comp., Extr. Colocynth. Comp., aa gr. iv.; Fellis Bovini inspissati gr. ij. M. Fiant Pilulae lij. pro No. 214. R Sodas Sub-carbon. 9j.; Soda; Sulph. Jss. — X\- Infus Senna-, Infus. Calumbae, Aquae Pimentae, aa 3v.; Tinct. Cardamom. Comp. 3 j. M. Fiat Haustiu. 804 EPILEPSY—Complicated— Treatment of. 70. D. From Disorder ofthe Generative and Urinary Organs.— The cause* (§ 37.) of this va- riety should be ascertained and removed, otherwise medicine will be of little service. The treatment should depend chiefly upon the degree of vascular fulness and action, in connection with the state of nervous power. When it has arisen from sup- pressed catamenia, or from amenorrhea, without any chlorotic appearance, bloodletting may be safely prescribed and repeated; and the usual means of restoring this evacuation resorted to. But when the fits appear before the catamenia are established, the period of puberty having arrived, blood-letting must be more cautiously employed, unless there be evident plethora, when it may be prescribed much more freely; and it should be aided by such emmenagogues and purg- atives as the habit of body, diathesis, and strength of the patient will warrant. If the disease be attended by signs of irritation of the uterus or ovaria,or by hysterical symptoms (§ 37.), heating and stimulating emmenagogues and antispasmodics should be laid aside, and those of a cooling and sedative kind prescribed, such as nitre with the subcarbonate of soda or of potash, with hyoscy- amus or the preparations of hop. When the fits follow the subsidence of regular and free uterine evacuations, vascular depletion is very seldom beneficial; the antispasmodic tonics, as valerian, the ammoniated tincture of valerian, assafcetida, the metallic sulphates, &c, occasional purga- tives, and strict attention to the digestive func- tions, being much more appropriate. If the fits be connected with dysmenorrhcea, or scanty men- struation, vascular depletions, especially from the feet immersed iu warm water, are generally of service, when the habit is full or the strength unimpaired. After the necessary evacuations, large doses of camphor combined with opium or hyoscyamus, also in large quantities, will gene- j rally relieve the more urgent symptoms. This practice has been pursued by me for several years, ] and has very recently been recommended by Dr. Cheyne. Semicupium, or the hip-bath, the in- ternal use of the sub-borate of soda, and frictions ofthe lumbar region, abdomen, hips, and thighs, night and morning and after coming out of the bath, by a hard flesh-brush, or by flannel, will also be useful adjuvants. If the attacks occur about the commencement of the menstrual period, the ap- plication of a number of leeches near the groins, J or on the insides of the thighs, shortly before the expected time, will often render the attacks more and more slight, and increase the discharge. Se- tons or issues in the latter situation will sometimes have a similar effect. If the catamenia be too abundant, or too frequent, or if symptoms of in- anition or asthenia be manifest, the invigorating measures already advised ought not to be neg- lected. The connection of this form of the dis- ease with manustupratio, or with great irritability of the sexual organs, should be kept in recol- lection; and where either the one or the other is detected, or even suspected, a strict mental and moral discipline, with the means recommended above (§ 62.), ought to be instituted. An oc- casional full dose of turpentine, either conjoined with some other purgative, or preceded by a dose of calomel, or followed by a brisk cathartic, and turpentme enemata, are sometimes of great ser- vice, particularly when the fits proceed from suppressed, obstructed, or difficult menstruation. Dr. Prichard advises the turpentine, in this state of the disease, to be given in an emulsion, in doses of from half a drachm to two drachma three times a day, or two drachms every night; but in this mode of exhibition it is generally nauseated, and is often productive of disagreeable effects, unless it be conjoined with some other purgative. If the fits be connected with disease of the urinary organs (§ 37. 6.), the alkaline car- bonates, with hyoscyamus; and oily purgatives, or other remedies suited to the disorder of these organs ; will often prevent or relieve them. 71. v. Treatment of Complicated Epilepsy.— The complicated states, being evidently, in a large majority of cases, caused by advanced grades of the same pathological conditions as pro- duced at first the simple epileptic paroxysms (§ 28. 51.), generally demand similar measures to those directed in the cerebral forms, but in a more energetic and persevering manner, especially when occurring early in the disease, and in young or robust persons.— A. The com- plication with mania or insanity will require, according to the history, the stage, and the exist- ing circumstances, of the case, either copious depletions and evacuations, or an invigorating treatment, conformably with the principles already stated. Chrouic inflammation of the brain or of its membranes should always be dreaded in this unfavourable form of the disease; and wherever the state of the circulation, and the symptoms referrible to the head and organs of sense, espe- cially the pulse in the carotid, and the tempera- ture of the scalp, evince its existence, general or local bleeding; the cold affusion on, and sponging, the head ; purgatives; mercurials with anti- monials, particularly calomel and James's pow- der ; external derivation; irritating liniments, setons, or issues, &c. ; should be employed, ac- cording to the habit of body and degree of vas- cular action and vital power. When the com- plication is of a maniacal kind, and vital power is not much impaired, these means may generally be energetically prescribed; repeated local de- pletions, the spirits of turpentine in purgative doses, and calomel with antimony pushed so far as to affect the mouth, being often of great service, especially if it occur in young robust persons, or from the suppression or disappearance or some other disorder, or of accustomed evacu- ations. But when the mental disturbance has slowly supervened, or attended an asthenic state ofthe disease (§ 27.); or has arisen from causes productive of exhaustion or inanition, consisting more or less of the low forms of insanity, or of mental weakness; the treatment advised with reference to the nervous or asthenic form of cere- bral epilepsy (§ 61, 62.) must be pursued; ex- ternal derivatives, and free alvine evacuations, being also directed. In this complication, the functions of the heart, digestive canal, liver, and uterine organs, should be duly regulated, as al- ready recommended in the sympathetic varieties, whenever they present any manifest disorder. 72. B. The apoplectic complication (§ 40.) must be treated conformably with the principles explained in the article Apoplexy. But my experience enables me to state that bloodletting can seldom be safely carried so far in it as in true apoplexy; and that cupping on the nape of the EPILEPSY — Remarks on Remedies recommended bv Authors. 805 neck, leeches behind the ears and to the temples, purgatives frequently repeated, brisk cathartic enemata, and external derivatives, are chiefly to be confided in. After recovery from the seizure, the measures appropriate to the habit of body and other circumstances of the case, as described with reference to the sanguineous form of cere- bral epilepsy (§63.), should be resorted to. The intermediate states between apoplexy and epi- lepsy (§41.) will require local depletion, alvine evacuations, and restorative medicines, according to the evidence furnished of vascular fulness, or of vital and nervous depression. In the intervals, stomachic purgatives, and antispasmodic tonics, with regulated diet, change of air, &c, will gene- rally be necessary. When these states are con- nected with disorder of the uterine functions, the measures directed in the uterine form of epilepsy should be prescribed. 73. C. The complication with paralysis (§ 42.) will seldom be treated with any success, unless the palsy be partial, and pass off soon after the fit; when we may infer that it has been owing to the congestion attending the convulsion. When the patient is young, of a full habit, or of unim- paired powers, bloodletting, general or local, or repetitions of the latter, will be requisite; aided by purgatives, setons, and the other means advised in the apoplectic complication. But in persons presenting evidence of asthenia or inanition, the preparations of iodine, especially the hydriodate of potash, and ioduret of iron; the extract of nux vomica with aloes, or the aloes and myrrh pill, or strychnine, in any of the forms given in the Appendix (F. 542. 565. 907.); and the metallic sulphates, with the antispasmodic tonics, espe- cially valerian, serpentaria, assafcetida. camphor, ammonia, &c.; will be most beneficial. But, even in these cases, purgatives should not be neglected; such as are of a warm stomachic kind being selected, and exhibited regularly every second or third day, so as fully to evacuate the bowels. In the more sthenic states of this variety, complete recovery from the paralytic symptoms is sometimes witnessed after free evacuations; but the patient is not secure from a return of the paroxysm in some one of its most dangerous states of complication, although his health may appear quite re-established. In a case to which I was lately called, these symptoms disappeared after full bleeding from the arm, copious purging, &c.; and the patient was able to pursue his occupation, and expressed himself quite well: but in a few days he was seized with another fit, of which he died in a few minutes. The bloodletting which I directed in this case was large; but the habit of the patient, the state of the pulse and of the blood drawn, and the effect produced by it, indi- cated the propriety of having recourse to it in a decided manner. 74. D. Of the other complications (§ 43.) of this malady, little further need be adduced. They require more especially a persevering use of sto- machic and deobstruent purgatives, with anti- spasmodics, external derivatives, and due attention to diet and regimen, varied and associated with other means according to the particular nature of the complication,or sympathetic disorder, and the habit of body and other circumstances ofthe case. 75. vi. Remarks on the Remedies and Means of Cure recommended by Authors,with reference 68 to the Varieties and Circumstances in which they are most appropriate.—A. Bloodletting, general and local, has been recommended by most wri- ters; but the extent to which it may be carried has rarely been understood, and never attempted to be assigned. At the present day, it is more fre- quently carried too far than neglected when it ought to be directed. Of modern writers, Dr. Cullen and Dr. Bright have estimated it in a manner which approaches the nearest to the results of my own experience. If carried too far, or performed in such a manner as to induce full syncope, it is apt to bring on a paroxysm; and if it be not followed by purgatives, restricted diet, and regular exercise, it will only increase the tendency to plethora. The circumstances in which it should be prescribed, as well as those in which it ought not to be resorted to, have been explicitly stated; but the extent to which it should be carried, the particular situation and manner of performing it, and the repetitions of it, can be regulated only by the existing circumstances of the case,—by the habit of body, the state of the pulse, the modes of living, the strength of the patient, and the causes producing and tending to perpetuate the malady. Dr. Heberden ex- presses himself strongly against bloodletting: but the class of persons amongst whom he prac- tised, and the inhabitants of large towns, subject to this disease, certainly are not so much bene- fited by this evacuation as those otherwise circum- stanced; and yet, even in them, very small and often-repeated local depletion is frequently of great service. 76. B. Purgatives, and purgative enemata, have nearly all writers in their favour; and I believe that there is no class of medicines which is less capable of abuse in this disease than they. But the success of the practitioner will depend chiefly upon the selection and combination of them ap- propriately to the peculiarities of the case; and upon his firmness in persisting in them, when they are clearly indicated, although little apparent benefit at first results from them. The more drastic purgatives, as elaterium, croton oil, and the hellebores, have been prescribed; and are most suitable in the plethoric states, and apoplectic, paralytic, and maniacal complications of the dis- ease. The frjetid, black, and even the white helle- bores have been recommended from Hippocrat- es to the present day; and are often very service- able in the verminous and uterine varieties, and in the maniacal complication, in which they have been prescribed byCELSus, Aret.sus, Alexander Trallianus, Schulz, Starkf., Smyth, Greding, and Prichard. Pliny states that the tribune Drusus was cured of epilepsy by the black hellebore. The powder ofthe root, or the extract, may be given in doses of ten grains in- creased to thirty; or the decoction of the leaves or root may be employed. In the apoplectic and paralytic complications, the extract or decoction are advantageously given in enemata. The oil of turpentine, especially conjoined with castor oil, in order to insure its cathartic operation, is a very efficacious medicine, exhibited either by the mouth, or in clysters. It is, in the latter mode of administration, the safest and most active of anti- spasmodics that can be given during the paroxysm; and, when prescribed in energetic doses, and suit- ably combined, it produces a very remarkable 806 EPILEPSY—Remarks on Remedies recommended by Authors. derivative action from the head, whilst it fully evacuates the intestinal canal, and stimulates the abdominal organs. Hence it is especially ser- viceable in the enteric, verminous, uterine, apo- plectic, maniacal, and paralytic states of the disease. It has been employed successfully by Latham, Young (Trans, of Coll. of Phys.vol. v. p. 52.), Percival (Edin. Med. and Surg. Journ. vol. ix. p. 271.), Lithgow (Ibid. vol. xi. p. 301.), Prichard, and by myself (see Med. and Phys. Journ. for May and July, 1S21.) The ancients, as well as the moderns, have de- pended also upon scammony, colocynth, and aloes; but of these, as well as of calomel, it is unneces- sary to make further mention. Dr. Heberden was averse from the use of purgatives, excepting in the enteric variety, owing probably to the reason assigned above (§ 75.); and certainly, in the more asthenic states of the disease, and when the circulating fluids are deficient in quantity and quality, if trusted to mainly, they will be produc- tive of mischief rather than benefit. In such cases, they should be given only on alternate days, or every third day,—should be of a warm and stomachic kind, or combined with tonics, and as- sociated with the means recommended above (§ 67.). Thom, J. Frank, Kinneir, Man- gold, &c, prefer rhubarb, the neutral salts, and the supertartrate of potash. This last, given in large doses, is most serviceable, when persisted in, if the vascular system be plethoric, and the biliary secretion in a morbid state. Galen and many recent writers have preferred aloes. In some one or other of its preparations and combinations, it is the most generally appropriate purgative that can be prescribed. With stomachic, chalybeate, and cardiac medicines, it is suitable in the asthe- nic cases; and combined with ox-gall, or with sulphate of quinine, or with bitter extracts, &c, it will act with very remarkable energy, and with- out depressing vital power,—a circumstance of peculiar importance in the treatment of epilepsy. 77. C. Emetics have been recommended by Aretjeus, Alexander of Tralles, Zacutus j Lusitanus, Ettmullf.r, Roncalli, Werl- hoff, Lettsom, J. Clarke, and others. Van j Swieten and J. Frank assign, with much pro- priety, the circumstances in which they should be ' given, in prescribing them only when the fits ap- j pear to proceed from disorder of, or the irritation j of morbid or noxious matters in, the stomach. Df. j Ha e n directs them when the paroxysm is preced- ed by nausea; Tissot, when a sense of weight, or a ravenous appetite, is felt; and Richter, shortly before the expected return of the fit. -Ma- J yer is favourable to the use of them, particularly oi ipecacuanha, exhibited in doses short of pro- ! ducing full vomiting; and Marryat prefers those containing the sulphate of copper. Heberden considers them injurious; and Frank remarks, that he has never known an instance of a cure hav- ing been effected by them, although he believes that they have cleared the way for the action of j other medicines. I agree with Mil bo m , in restrict- ing them to the stomachic form of the disease, and in considering that they may be injurious in most other states, especially when there is much vas- cular fulness, or cerebral congestion. 78. D. Diaphoretics are much praised by Tis- sot and Les tin, who consider it of much impor- j tance to promote a free and equable perspiration, which is seldom observed in epileptics. James's powder, as prescribed above, or the other prepa- rations of antimony, may be selected, particularly in plethoric persons; or the vinum ipecacuanha may be given with liquor ammonia acetatis, and the spiritus etheris nitrid. These are, however, most serviceable after other evacuations have been em- ployed; and when the skin is dry; and then their operation may be aided by the tepid bath, as advised by Tissot and Marcard. Dr. Aber- crombie,according to Dr. Cooke, has seen be- nefit from the tartrite of antimony given four times a day, in such doses as the stomach could bear. I had recently a patient under my care, who experienced a very severe attack whilst he was under the influence of this medicine. 79. E. Emmenagogues are required in those states of the uterine form of the disease that are connected with delayed, suppressed, or difficult menstruation. The oil of turpentine is one of the most efficient of this class of medicines that can be given in such cases, as fully shown by Dr. Prichard, more especially after bloodletting from the feet, or leeches to the groins and tops of the thighs, and the hip-bath, or semicupium, have been prescribed. The sub-borate of soda is also sometimes of service, either given alone, in doses of ten or fifteen grains; or in conjunction with other emmenagogues and antispasmodics,—more especially with camphor, or valerian, castor, am- monia, galbanum, assafcetida, aloes, &c. (F. 268. 368.) But, as 31. Maisonneuve justly remarks, the restoration of the uterine functions to their healthy state is not always followed by a cure or even alleviation of the disease. When this is the case, the treatment must proceed according to the principles already explained. Marriage has occasionally removed the seizures, especially in the female, as remarked by Stahl (De Dispos. Hered. ad Var. Morb. p. 48.), Hoffmann (De Epilep. Opp. vol. iii. obs. 9. p. 20.), Krunitz (De Matrimonio Multor. Morb. Remedio. Franc. 1749.), Morf.au (Mem. de la Soc. Mid. d''Emu- lation,t. ii. p. 189.—in the male.), and Prichard (Op. dt.). A young lady, whom I long attended on account of slight epileptic seizures, connected with irregularity of the uterine functions, and of the bowels, experienced, after marriage, a gradual amendment for some time; but had a very severe attack of puerperal mania after her first child. She is now in good health. 80. F. Tonics and Antispasmodics.—In the asthenic states of the disease, and in the other varieties, after bloodletting and the foregoing evacuations have been actively prescribed, re- medies possessing a tonic and antispasmodic action are chiefly to be depended upon. But these should be selected with reference to the results of experience as to their operation, to the form of the disease, and to the particular features of the case, especially the states of sen- sibility and irritability, and of vascular fulness and action, generally and locally. But even when such remedies are most necessary, pur- gatives should be so conjoined, or so alternated, with them as to preserve a regular action of the bowels, or to occasion a brisker operation once or twice a week, according to the strength of the patient. In many cases, also, it will be requisite to administer tonics, and, still more frequently, antispasmodics, even contemporaneously with EPILEPSY — Remarks on Remedies recommended by Authors. 807 local depletions, more especially when general or local plethora is associated with defective power and increased susceptibility. 81. a. Oi mineral tonics and antispasmodics, the most active are the metallic sulphates and nitrates. — u. The preparations of copper, particularly the cuprum ammoniatum, or the simple sulphas cupri, have been recommended by Aret.eus, Boerhaave, Van Swieten, Weizenbrey- er, Duncan, Baumes, Thilenius, Theus- sink, 31ic ha elis, Cullen, Stone,Gre ding, Bland, Vogel, Willan, Battie, and Reil; and employed by them successfully in many cases. Drs. Home, Hook, and Magennis, however, state that they have found it to fail in most instan- ces. Dr. F. Hawkins expresses himself much iu favour of the sulphate, in doses of a fourth of a grain, conjoined with sulphate of quinine, or cinchona. In the asthenic states, and in the more plethoric forms, after depletions and evacuations have been prescribed, this combination, and the ammoniated preparation, frequently produce very great benefit, and sometimes entirely cure the dis- ease. Dr. Urban (Hufeland, Journ. d. Pr. Heilk. 1827.) prefers the ammoniacal sulphate in the simpler states of the affection; and prescribes eight grains of it in forty-eight pills, of which three are to be taken night and morning, increas- ing the dose by one pill each second day. 82. ■}. The sulphate and oxide of zinc have been prescribed by Hart, Martini, Hartmann, Crell, Aasheim, Bell, Percival, Guth- rie, Haygarth, Rush, Arnaud, Richter, and Ranoe. Osiander directs the zinc with valerian and orange leaves. The oxide has been preferred by most of these writers; and Dr. F. Hawkins advises it to be given with extract of conium. I have combined it advantageously with the ammoniated copper (F. 159. 598.), with cam- phor (F. 615.), and with valerian (F. 582. 665.); but I believe that the sulphate is more efficacious, especially when conjoined with camphor, musk, or other antispasmodics. (F. 584—587.). Upon the whole, zinc appears to be less useful than copper in this disease, although I do not rank it so low as Dr. Cullen and Dr. Cooke have done, who employed chiefly the oxide, which is frequently inert,unless it be exhibited in large doses. 83. y. The nitrate of silver seems, from a pas- sage in Stahl ( Theoria Med. Vera. p. 1019.), to have been given in this disease as the principal ingredient of a secret medicine much employed in some parts of Austria at the time when he wrote; having been probably adopted from the prepar- ation described by Angelus Sala, which con- sisted of a solution of the salt in wine; and which he directed in so large doses as to act as a cathartic. Schroeder, however, had already recommend- ed it in epilepsy and other diseases of the head. Both Sala and Geoffroy prescribed it as a purgative in dropsies; but, although Schroeder, and Boerhaave had mentioned it as a cure for epilepsy, it was scarcely used until Dr. Wilson noticed (Duncan's Annals of Med. vol. ii. p. 405.) its good effects. It was afterwards adopted by Dr. Sims, Dr. Cappe, Dr. Powell, and many others, who published proofs of its efficacy. Subsequently, Dr. Baillie, Dr. Roget, Dr. R. Harrison, Dr. J. Johnson, Dr. Cook, Dr. Sementini, 31. Valentin, Dr. IIeim, and others, have prescribed this medicine with advan- tage; and the more numerous observations of M. Lombard have also proved its success in a very large proportion of cases. The discolouration of the skin by it, noticed by Albers, Roget, J. Johnson, Vetch, and others, is so frequent, ■ and so permanent when it does occur, as to be a serious objection to it. In some of the cases in which this effect was produced, the disease was not removed ; but in others the recovery was complete. It does not seem to depend so much upon the largeness of the dose, as upon the long continuance of its use. Sementini (Giornale di Fisica, t. xi. p. 355.) recommends this salt to be triturated with some vegetable extract, and given in the form of pill; in this stale the dose may be gradually increased to six or eight grains, or even more, in the day. I have prescribed it thus in several cases of epilepsy, and other dis- eases ; and frequently with great benefit. It should not be continued very long, without inter- mitting it for a while. An eruption of minute pustules over the surface of the body, sometimes is produced by it, as first remarked by Semen- tini, and observed by myself; but this should be viewed as a favourable circumstance. The ni- trate of silver appears to me most beneficial in the asthenic states of the disease; or after evacu- ations have been practised, in the other forms; also in the stomachic and enteric varieties, and in the complication with paralysis. I have general- ly combined it with hyoscyamus, or camphor (F. 473.), extract of belladonna (F. 472.), musk, opium (F. 475.), or gentian (F. 174.). The fol- lowing is the mode of administering it adopted by Heim, an eminent physician in Berlin: — No 215. K Argenli Nitratis in Pulv. gr. xij. ; Opii Puri gr. vj. ; Extr. Conii Maculati 3'j-' Extr. Glycyrrh. 3 j- Tere bene, et divide in Pilulas ponderis granorum duorum. Mane et vespere iij.—v. pil. capiat. 84. . Camphor may be employed in every form of the disease, but in very different doses and combi- nations; iu the plethoric states, in small quantity with diaphoretics and refrigerants (F. 24.); in the asthenic, enteric, and uterine varieties, in full doses with tonics and other antispasmodics (F. 35. 615.). Locher (Observ. Pract. No. 40.) prescribed it with bark; and Tissot, Pinel, and most modern writers have employed it, either as the chief agent, or as an adjuvant of other sub- stances. When an immediate effect is required, it should be given in the form of draught or mix- ture, with the preparations of ammonia or of the EPILEPSY—Remarks on Remedies recommended by Authors. 809 tethers (F. 186. 212. 423. 845.). It often shortens the fit, or prevents it altogether when exhibited in enemata shortly before the usual period of acces- sion, as in Formula? 130. 135—138. 151. 87. c. Of animal substances, castor, musk, and ox-gall are most deserving of notice. — a. Castor is recommended by Aretjeus, Celsus, Pliny, Skrapion (apud Ctel. Aurel. p. 352.), K. Dig- by (Experim. Med. p. 332.), Moor (Pathol. Ce- rebri, p. 211.),Thouvenel (Sur les Vertus des Subst. Anim. Medicam. p. 357.), Tissot, and Fothergill. When unadulterated, and given in full or large doses, it is often of much service; especially in the asthenic, dyspeptic, and uterine varieties; and in the combinations advised in re- spect of assafcetida and camphor, with which (as well as valerian and musk) it may be conjoined (F. 480. 497. 905.).—(?. Musk is also beneficial in these varieties, or in the other forms after evac- uations have been prescribed, and in similar com- binations to those mentioned with reference to the preceding substance. It is favourably mentioned by Feuerstein, Van Swieten, Quarin, Cullen, Ackermann, and others. Hannes made a full and successful trial of its efficacy on his own son (See Nova Acta Nat. Curios, vol. v. p. 244.). It should, unless intended merely as an adjuvant of other means, be given in much larger doses than usually directed. It may be conjoined with camphor, sulphate of zinc, &c.— y. The bile of various animals, particularly of the ox, bear, and dog, has been noticed by Bartho- lin, Unzer, Quarin, and others. Of inspissa- ted ox-gall I have had some experience in this complaint; but have usually directed it in combi- nation chiefly with assafcetida, galbanum, myrrh, aloes, &c. (F. 558. et seq.). It is of much ser- vice in the states just particularised, and after de- pletions have been carried far, or to an injurious extent. In a case of this latter description, I am now employing it with very marked advantage. 88. d. Cold or salt water bathing has been advised by Celsus, Gelius Aurelianus, Floyer, Lentin, Tissqt, and Hufeland; but it requires caution, and attention to its effects. In young persons and delicate females, who have not been accustomed to a plunge bath, the fear, or shock of immersion, may bring on the seizure : indeed, Wiekard (Observ. Med. Franc. 1775.) and Tode (Med. Chir. Bibl. b. i. p. 117.) ad- duce instances of such an occurrence. The show- er bath, used daily, commencing with tepid water, and gradually reducing the temperature, in cases where the shock may be dreaded, is of much less equivocal benefit; and is, in all the varieties, but in the simple or cerebral forms especially, a very excellent remedy. When it cannot be employed, the patient should daily affuse water from a large sponge over the whole head and occiput. 89. G. Numerous substances evincing more of stimulating, than of tonic and antispasmodic, pro- perties have been prescribed, with occasional suc- cess; but, in general, in combination with one another, or with medicines producing an astrin- gent or tonic effect.—a.—a. The oil oi hartshorn, or Dippel's animal oil, was very generally used, both internally and externally, especially during the last century, owing to the recommendations chiefly of Dippel (Disquisit. de Vita Animalis MorboetMed. fyc. p. 89.), Alberti (DeMed. in Motibus Nat. Exacerbatis. Hate, 1718.), I 68* Vater (De Spedficor. Epilep. Sigillatim Old Animal. Virtutibus. Vitel. 1725.), Mauchart (De Oleo Animal. Dippellii. Frib. 1745.), Juch, Kortum, Bang, Thouvenel, Cullen, Mo- rand, and Portal. Feuerstein believes that, when it is pure, and not altered by the action of the air, it is often beneficial. Ackermann con- siders it possessed of no small efficacy in the as- thenic forms of the disease, particularly those con- nected with anaemia, and languor ; but hurtful in the irritableand plethoric states. Quarin ad- vises it in the uterine variety. Tissot, however, thinks it possesses but little power.—p. Cajeput oil was prescribed with benefit by Goetz (in Commerc. Lit. Noric. 1731, p. 5.), in doses of from two to ten drops on sugar; and by Werl- hof (Oper. Med. p. 711.), with cinchona.—y. The oil and other preparations of amber have been found sometimes useful by Riverius (Prax. Med. p. 32.), Be attie (De Cognoscend. et Cur. Morb. fyc. Halae, 1780.),Cullen (Mat. Med- ica. vol. ii. p. 361.), and others. The oils of hartshorn, cajeput, valerian, and amber, are ser- viceable chiefly in the simply nervous and asthenic states of the disease; and are useful adjuvants of other medicines, and are often beneficially con- joined with narcotics (§ 97.). Besides these, other oils, both simple and medicated, have been prescribed; but they hardly deserve enumeration. 90. 6. Phosphorus was, I believe, used for ep- ilepsy first by Kramer (in Commerc. Lit. Noric. 1733, p. 137.); and more recently by Feuer- stein, Quarin, and others. Weikard, Au- tenrieth, and Hufeland justly view it as a doubtful and dangerous remedy. Haartmann (De Noxio Phosph. in Med. Usu, Sec. Aboae, 1773.) gave it in four cases without benefit. — ji Cantharides has been tried internally, by Mer- curialis (De Morb. Pueror. 1. i. c. 3.),Zacu- tus Lusitanus (Prax. AdmirabA. i. obs. 35.), Stockar (De Usu Canth. Interno. Goet. 17S4. p. 34.), and Dr. J. Johnson (On Derangements ofthe Liver, Src. p. 105.), with occasional advant- age. Its external use, is, however, more com- mon, if not more beneficial, in this complaint. 91. c. Guaiacum, either in decoction or sub- stance, has been employed by Vesalius (Hal- ler's Bibl. Med. Pract. vol. ii. p. 32.), Willis (De Morb. Convuls. p. 460.), Sennert (Prax. Med. 1. i. c. 31.), Mercurialis (Respons. et Consult. 1. ii. c. 3.),Forestus (Observ. Med. 1. x. obs. 58. 63.), F. Hoffmann (Med. Rat. Syst. t. iv. p. iii. c. i. p. 21.), and others, who consid- ered it possessed of much efficacy in this com- plaint, especially if connected with a syphilitic taint; but it has been neglected by more modern writers. — y. The flowers of the Cardamine pra- tensis were found beneficial by Berger and Nagel (De Usu Med. Card. Prat. &c. Franc. 1793. p. 13.); but Baker (Trans, of Coll. of Phys. vol. i. p. 443.), Lysons (Pract. Essays, fyc. p. 173.), and Greding, state it to be inef- ficacious. The saturated infusion of the flowers and leaves produced a copious and fcetid perspira- tion in the experiments made with it by Berger (De Remed. Spec, in Ep. fyc. Franc. 1795. p. 11.) — koyv, with as- safoetida ; Huxby, with musk ; and Ferriar (Med. Hist, and Reflect, vol. i. p. 34.1, with musk and camphor. De Haen and Darwin pre- scribed it alone, at bedtime, successfully, in cases in which the fits came on during sleep. Ward and Portal applied it with benefit, externally to the part winch appeared to be the seat of irri- tation. PaNZANi (Giornale di Med. t. xiii. Ven. 1776.) exhibited as much as four grains with permanently relieved four, and temporarily re- lieved eleven. He remarks, that aperients, tonics, and antispasmodics should also be exhibited. Arnemann (Pract. Arznrimittellehre, th. i. p. 279.) advises it to be given in the form of pill with camphor and bitter extracts. 99. c. Hyoscyamus, as well as stramonium, is indicated only in the circumstances and states of the disease pointed out when remarking on the use of opium and morphine (§ 97.), and in similar combinations to them. Mayf.rne (Synt. Prax. Med. Lond. 1690. p. 23.) prescribed the seeds, commencing with six or eight grains, gra- dually increasing, in the course of forty days, the dose to twenty-four grains; and directed them to be taken in the expressed juice of the semper- vivum. Stoerck employed the extract, the pre- paration adopted also by Sauvages, Lentin, Bang, Greding, andOBEUTEUFFER, who de- rived from it only slight or temporary advantage. —Conium has likewise been employed by Sto- erck and some other writers, chiefly with liquor potassa;, when the disease is connected with the scrofulous taint. 100. d. The powdered root and leaves of bel- ladonna, and the extract, are recommended by Munch, father and son, Stoll, and Bottcher. Richter, L6benstf.in-L'6bel, and Hufe- land (Journ. d. Pr. Arzn. b. ix. p. 100.) pre- scribe either of these, with tonics, antispasmodics and aperients, according to the nature of the case. Greding (Ludwig's Adversaria, b. i. par. 4.) considers this plant to possess but little efficacy. Kaufer and Munch, the son (De Usu Bella- donna in Melanchol. et Epileps. Goet. 1783.), advantage in a case complicated with maniacal '• however, contend, that it is especially beneficial delirium. It is seldom of any use in the heredi- i when the fits are followed by maniacal alienation tary disease, or in that occasioned by the sup- I or tremors. It is most suited to the atonic states, pression of accustomed evacuations, — indeed, it may be injurious in the latter ; and, as Quarin (Animad. Practica, p. 20.) justly remarks, it may induce a state of apoplectic torpor, when giveu during the paroxysm. The preparations of morphine, especially the acetate, in the liquor ammonias acetatis and camphor julap, or with an aromatic spirit, are frequently preferable to the pure opium, and less likely to affect the head in- juriously. I have found the following draught to agree even with those who could not take opium m any of the more usual forms :— *f... 216. K Morphin* Acetatis g-. \; solve in Liq. i Am- monia- Acetatis 3 jss., et adde Mist. Camnhora; (vel Aa. l'cstillal*) 3; ; Spirit. Caryoph. 3j.; Olei Anisi H| nj. M Fiat Haustus. , , 98. 6. Stramonium, principally its extract, has been much employed in epilepsy, by Continental writers. Stoerck (Libellus, quo demonstrate conjoined either with ammoniated copper, or with nitrate of silver (F. 472.), or with musk, castor, camphor, &c.— Tobacco is stated, by Sennbrt, Zacutus Lusitanus, and Dupau (in Journ. de Med. Sept. 1789.), to have been used suc- cessfully, in the form of clyster, in the stomachic and verminous associations of the complaint. Currie directed epithems of the infusion over the epigastrium before the accession of the fit, with benefit. 101. I. There are many other substances which have been employed internally in this dis- ease __a Digitalis is one of the most important of these. Parkinson (Theater of Plants,p. 654.) remarks, respecting it, that " divers have been cured of the falling sicknesse thereby ; for after I takin" of the decoction of two handfulls there- | of, with four ounces of the Pollipody of the oake 812 EPILEPSY—Remarks on Remedies recommended by Authors. bruised, in ale, they that have been troubled with that disease twenty-six years, and have fallen once a week, or two or three times a moneth, have not fallen once in fourteen or fifteen moneths." Salmon and Withering also praise it; but Currie (Mem. of the Med. Society of Lond. vol. iv. p. 18.) gave it in three cases with only temporary benefit. Dr. Percival (Edin. Med. and Surg. Journ. vol. ix. p. 271.) also tried it un- successfully, but in an unsatisfactory manner ; for it is not by the empirical exhibition of one or two large doses of this medicine, that good effects can be obtained from it in a chronic complaint. Its efficacy in small doses has been shown in two cases (Amer. Med. Recorder, No. 2.) ; and in one that came under my own observation. It has been favourably noticed also by Dr. Briggs and Mr. Scott (Edin. Med. Journ. Jan. 1827.) ; and by Knight, who has found much benefit from it in epileptic insanity. Dr. Sharkey re- commends an infusion of it in porter to be given until vomiting supervenes. It is advantageously exhibited also in conjunction with tonics, anti- spasmodics, and anodynes (F. 456. 469. 514. 537.) ; and is most serviceable when the disease has been caused by fright, or is connected with disorder of the heart. 102. 6. The preparations of mercury have been used in epilepsy for their alterative effect, and in combination with various antispasmodics, or with antimonials. Of the propriety of these in the venereal and hepatic associations of the com- plaint, no doubt can be entertained. But in other circumstances they require discrimination. In the inflammatory or congestive states, and eith- er alone, or with James's powder, they are often beneficial, although they be carried so far as to affect the mouth. Piso and Rolfinck, Scar-' dona,Walther,M. Hoffmann (Eph.Ac. N. C. cent. 1. et 2. p. 272., et Ibid. cent. 3. et 4. p. 231.), and Rahn, have adduced proofs of the good effects of salivation in some instances. When we reflect on the frequency of serous effiision in the cavities, and of alterations of the coverings of the brain, in fatal cases, a judiciously conducted course of mercury, independently of the evidence of VVi l- LlS.RlEDLIN, EtTMULLER, LOCH ER, TlSSOT, Burseri, Lysons, Frank, Sporry (Ueb. die Wtlrk. des Quicksilbers in der Epil., in Mus. der Heilk. b. i. No. 35.), and others, in its favour, I promises some benefit. It is chiefly, however, in the more active conditions, or when the ma- lady presents the apoplectic, inflammatory, ma- niacal, or paralytic complications ; or follows some acute cerebral disease, and the pulse retains considerable firmness; that mercury, given so as to affect the mouth, is most likely to be service- able. In these, calomel or blue pill with antimo- | nials, or mercurial inunction, may be employed ; j but iu the more asthenic and chronic cases, either these preparations should be conjoined with anti- spasmodics, a3 camphor, castor, or musk, as di- rected by Bang ; or the sublimate should be given dissolved in sulphuric aether (J. Frank), or in tincture of bark ; or hydrarg. cum creta, or Plum.mer's pill, with James's powder, Castile soap, or any other substance that the peculiarities of the case will suggest. 103. c. The elutriated oxide of tin has been recommended by Dr. Shearman, in the dose of • two scruples to a drachm to an adult, night and ' morning, continued for four or five days, an active cathartic being exhibited on the fifth day, and the tin again resumed, according to its effect.—The superacetate of lead has been prescribed by Mayerne, Saxtorth (Acta Reg. Soc. Med. Haun. vol. iii. p. 90.), Rush (Philad. Med. Mus. vol. i. p. 60.), and Eberle (Lond. Med. Repos. vol. viii. p. 178.) ; and the hydrochloric acid, by Larrey, chiefly in the syphilitic and cachectic states. 104. d. The Agaricus muscarius has been found serviceable in doses of from ten to twenty grains, by Whistling (De Virtut. Agar. Mus. \c. Jenae, 1773. p. 13.) ; the Boletus suaveolens, in doses of a scruple four times a day, by Enslin (De Bol. Suav. fyc. Erling. 1784. p. 77.) ; the Aconitum napellus, by Durande ; the root of the Dictamnus albus, by Stoerck; the seeds and root ofthe Heraclium spondylium, in doses of two or three drachms of the latter, by Pliny (Hist. Nat. I. xxiv. cap. 6.) and Orne ; the root of the Tussilagopetasites, by Cranz (Nat. Med. par. ii. p. 162.); the colchicum, by Alderson (Lond. Med. and Phys. Journ. vol. xxxvii. p. 17.) ; the Hyssopus officinalis, by Forestus,Ruland, and Sennert; the flowers of pimpernel (Anagallis arvensis), in doses of twenty grains three or four times a day, by Dioscorides and Gasser; the expressed juice ofthe Galium luteum, in doses of two or three ounces in the morning, by Chomel (Plant. Usuelles, fyc. t. ii. p. 24.), Gakdane ( Gaz. de Saute,1773, p. 19.),and \VEHDT(k~lin. Annal. p. 146.) ; the seed of the Lycopodium clavatum, by Schroeder and Kuhn; the Luna- ria rediviva, by J. Fran k; the watery extract of the leaves of yew (Taxus baccatus), in from one to ten grains in the day, by Loder (De Taxo Baccato. Jenae, 1794. p. 17.)andHuFELAND,in uterine epilepsy; the Cocos nucifera, by Thun- berg; the flowers ofthe Anchusa officinalis, by Brutz and Baldinger; the Bryonia alba, by Reusner; the essential oil ofthe Buxus semper- vivens, by Schroeder and Vogel; the flowers ofthe Lilium convallium, by Se n k e n b e r g , Ba l- dinger, and Langhan, in doses of a scruple to a drachm, in the periodic type of the complaint; the powdered leaves, the decoction, and the es- sential oil of the Origanum majorana, by Dios- corides, Schroeder, artd Fonseca; the ber- ries ofthe Sambucus niger, by Du fou r ; the decoc- tion ofthe Solanum dulcamara, by Boerhaave, in epilepsy from metastasis; the flowers and root of the Tilia Europea, by Hoffmann, Ruland, and Tilemann (DeMat. Med.p. 308.);the Verbena offidnalis, by Sebitz and Rosenstein; and the distilled water of the Prunus laurocerasus, by J. Frank. Neither of these require any remark, excepting this last, which, from the quantity of prussic acid it contains, is sometimes not without efficacy. Its active constituent, prussic add, is occasionally beneficial in the simple states of the complaint, after plethora has been removed, and the bowels fully evacuated, or when the disease is connected with great susceptibility and irri- tability, or is dependent on pain, local irritation, or gastric disorder.—Of internal treatment, gene- rally, it may be added, that every medicine will fail, or afford merely temporary advantage, as long as plethora exists, or active determination to the head is unrestrained, and the appetites are indulged. And I must subscribe to the justice EPILEPSY — Remarks on Remedies recommended by Authors. 813 of Hebf.rden's remark :—" Etenim nulla sunt remedia, quae non toties spes nostras fefellerunt, ut incertum sit quantum illis debeatur, ubi visa Bunt profuisse." (Comment. Src. p. 143.) It is chiefly by a judicious sequence, and combination of remedies; and by a well-devised plan, having strict reference to the circumstances of the case; that we can hope to treat this malady with success.* 105. K. Electricity was formerly much em- ployed, but is now seldom tried, in epilepsy. Deshais, Mangin (Hist, de VElectr. par. iii. Paris, 1752.), Morris (Gent. Mag. 1753. p. 379.), Linn^us (Consect. Electrico-Medica. Ups. 1754.), Franklin, and Lovet (Elect. rendered usefulin Med. Intentions. Lond. 1760.), furnished the earliest notices of its use ; but these were unsatisfactory, and almost contradictory. The more extensive experience, however, of Fel- ler (De Therapia per Electrum. Leips. 1785.), Feuerstein, Deimann, and Kuhn (Geschi- chte der Med. u. Phys. Elect, fyc. Leips. 1785. Svo.),demonstrated—what indeed might have been inferred a priori—that it is occasionally success- ful in cases characterised by debility, inanition, or torpor of the vital functions, and in those occa- sioned by frights; but that it is seldom beneficial, and may even be injurious, in the acute, plethoric, inflammatory, and hereditary states of the com- plaint. In cases caused by suppressed discharge, it is not always a safe remedy : for, although the experiments of Spengler and Kuhn have fur- nished instances of its success in such; yet those of Linnjeus, Feller, and Quarin, show that it was either inefficacious or hurtful, unless evacua- tions had been premised. Of the effects of gal- vanic electricity, the evidence is but little different from the foregoing. Mr. Whitlam (Lond. Med. Phys. Journ. vol. xiv. p. 527.), Dr. Duncan (Ann. of Med. vol. viii. p. 339.), and Mr. Mans- ford, havedetailed cases where this agent proved of service; but the last-named writer admits, not- withstanding his views as to the nature of the dis- ease (§ 50.;, that galvanism can often rank only as an auxiliary means. His plan of employing this agent is peculiar; and, although it may be the most rational and efficacious, it is seldom possible to have recourse to it; for, granting that the physician may manage, in the way Mr. Mansford directs, con- stantly to inclose the body of his patient within the circle of a galvanic battery; yet it may not * M. BoRlE'3 plan of treating epilepsy, wh'ch is in great repute in Paris, is as follows: —Haiing premised a small • bloodletting from the feet, exhibited an emetic, and acted on the bowels by means of four grains of calomel and an ounce of castor oil, he directs, every morning fasting twenty drops ofthe distilled laurel water, in a glassful of sugared water ; increasing the dose one drop daily until it reaches sixty, when lhat quantity is continued; and, every night, two drachms of the leaves of the artemisia, iu powder, in the infusion of the tilia Europea. He applies every fortnight, moxas — not exceeding six — along the spine, from the oc- ciput downwards; causes the lower extremities to be well rubbed, with some ajtherial preparation, twice daily; and leaves a bracelet on the left arm, which is to be drawn very tight upon the approach of the fit. He allows the patient only water for his drink, and restricts him to vegetable diet. He further directs sea bathing — the head being firsl :mmers- ed — or the shower bath, and exercise in the open air, avoi ling exposure to the sun : and lastly, he enjoins him— '• Eviter les emotions vives, les emportemens de colore, les occupations serieuses, les tensions de l'esprit, les lectures obscenes, la irequentalion des spectacles, li■■> contrarietes, les habitudes extenuantes, 1'onanisme, les plaisir« veneriens,"&c. (Journ. des Progris des Scir.n. MM. t. ii. \). S. p. 22H.) prove successful, or the benefit derived may cease with the discontinuance of its use. Of electricity and galvanism, it may be said gene- rally, that they have occasionally been found successful : that, when resorted to shortly before the seizure, they have sometimes suppressed it, or rendered it more mild; that, when applied during the paroxysm, they have often mitigated its violence and duration; and that the safest mode of employing electricity, is to place the pa- tient on the insulating stool, and subject him to the electric bath; and to draw sparks from dif- ferent parts, when thus insulated and placed in connection with the prime conductor. 106. L. Of external means, the most de- serving notice are setons, issues, moxas, open blisters, and artificial pustulation.—a. The actual cautery, applied to the nape of the neck, the oc- ciput, and even to the vertex, is recommended by AretjEus, Celsus, Cjelius Aurelianus, Avicenna, and several writers of the sixteenth and seventeenth centuries. At the present time, moxas have nearly superseded the cautery, and have received the sanction of the most expe- rienced writers, especially Esquirol and Lar- rey; the former of whom directs them along the cervix and spine, he having observed disease of the medulla oblongata and spinal cord in several instances. 107. b. Setons and issues have been directed by nearly every writer on the disease. In the cerebral variety with determination to the head, they are often serviceable ; but in the asthenic forms, or when evacuations have been carried too far, and when susceptibility and irritability are augmented, they often either fail, or increase the disorder, unless tonics and antispasmodics be administered. The nucha is the place usually selected for their insertion, but the insides of the arm, or thigh, are often preferable situations. Zacutus Lusitanus (Prax. Admir. 1. i. obs. 22.), Ab-Heers, Rochard, and Locher, di- rect either them, or the actual or potential caute- ry, to the seat ofthe aura. M. Andral prefers the latter means, and advises their application to a limb in preference to the nucha or occiput. An accidental burn of the limb, followed by ulcer- ation, has not infrequently effected a cure, as in the case detailed by Dr. Bona (Hufeland's Journ. 1827.). 108. c. Artificial pustulation by tartarised an- timonial ointment, applied to the nucha, occiput, or vertex, has been found serviceable by Dr. Carter (Lond. Med. Repos. vol. xix. p. 382., and vol. xxi. p. 369.), Mr. Creichton, and Dr. Mills, but it has, like all other agents, also failed. Horn (Archiv. 1812, May, p. 573.) directs this ointment to be rubbed on the part where the aura commences.—d. The propriety of exciting irritation in the scalp itself is ques- tionable in the inflammatory, plethoric, and acute cases; although Aretjeus recommends it, and Alexander Trallianus advisesmezere- on bark to be applied to this part. Where the dis- ease has followed the suppression of an eruption in this situation, the antimonial ointment, or the mezereon bark, or blisters, are very appro- priate applications. In the more obstinate and chronic cases, and after free evacuations in the more acute, blisters kept freely open, on the oc- ciput, behind the ears, or on other parts ofthe 79 814 EPILEPSY—Remarks on Remedies recommended by Authors. scalp, are prescribed by Riverius,Piso, Hoff- mann, Mead, Percival, and others.—e. Scari- fications of the scalp, particularly on the occiput, are directed by Celsus and Celius Aurelia- nus, and are deserving of adoption in modern practice.—/. Dry cupping on the neck and be- tween the shoulders shortly before the expected return ofthe fit, has been prescribed by me, with slight benefit, in some cases in which depletion had been carried as far as was judged prudent. 109. M.—a. Ointments containing the active principles of various medicines, as strychnine, veratria, acetate of morphia, &c, have very re- cently been tried in epilepsy, and are calculated to prove serviceable in some of its states; but, as yet, the results have not been such as to admit of further remarks.—b. Variously medicated epi- thems have likewise been resorted to, applied chiefly on the epigastrium, or along the spine. I have directed them in a few instances with ad- vantage, particularly in children, and have gen- erally employed modifications of F. 311. 313. and 770. in this manner.—c. The endermic method, or the application of various active substances to the skin denuded of its cuticle, has recently been tried on the Continent, in this disease. It possesses this advantage,—that it combines the operation of medicinal agents on the nerves of the part, and on the circulation, with external irritation ; and it therefore deserves a cautious adoption, and more extended trials than have hitherto been made of it. 110. N. Immediate ligature oi a limb or part, above the situation in which the aura com- mences, has been favourably noticed by Galen, Alexander Trallianus, Rhazes, Avicen- na, Schenck, Greding, Lysons, Pew,Cul- len, &c. and is generally recommended when the fit is preceded by an aura. It sometimes wards off the seizure; but it fails of doing so, as often as it succeeds, although it may have been sufficiently early employed. 111. O.—a. Aretjeus is the earliest author who has noticed trephining the cranium in epilep- sy, and the circumstances in which it may be per- formed. Celius Aurelianus was opposed to the practice, although he states Themison to have been in favour of it. Instances have, however, been recorded by Abernethe (Qutest. Medica Monspel. Src. Monps. 1617.), Rhodius (Observ. cent. i. obs. 66.), Van der Wiel (Observ. Med. cent. i. obs. 8.), Marchettis (Observ. Chirurg. Patav. 1664.), La Motte (Chirurgie, t. ii. p. 409.),Lysons (Essays, fyc. p. 111.),Kite, Tis- sot, and others,where external injury, and circum- scribed disease ofthe bone or scalp, have furnish- ed indications to warrant the performance of this operation; and where it was resorted to with suc- cess. It has also been practised recently with ben- efit. Dr. Elliotson refers to a case in St. Thom- as's Hospital, where the trephine removed a piece of bone with a spicula from its inner surface, and cured the disease. Other successful instances are recorded by Dr. Guild (Med. and Chirurg. Review, vol. xii. p. 504.), and Dr. Blake (Lond. Med. and Phys. Journ. Jan. 1826.).—6. The much less feasible experiment of tying the com- mon carotid, in order to cure the disease, has been suggested by Mr. Earlk, and actually practised by Mr. Preston ( Trans, of the Med. and Phys. Soc. of Calcutta, vol.v.); but its ultimate success ia not apparent.—c. Pressure on the carotids has been advised by Mr. Earlk; but it is pro- bable, that the obstruction it must occasion to the return of blood from the head, will be us in- jurious as the diminution of the supply may be beneficial. 112. P. Travelling, and change of air and of residence, are sometimes serviceable; and are recommended by Hippocrates and Hoff- man n. In the cases of children, change to a dry situation, or to the sea-side, is especially beneficial. Van Swieten (Comment, vol. iii. p. 436.) states, that several epileptics were cured by emigrating from Holland to the East Indies, and that, upon their returning to Europe, some experienced a re- lapse, but that others had recovered permanently. It is chiefly, however, in the asthenic and sym- pathetic forms of the disease, that change of air and travelling prove serviceable. 113. Q. Regimen.—In addition to what has been already advanced on this subject, the prac- titioner should bear in mind, that as much may be done by a regimen suited to the peculiarities of the case, as by medicinal agents.—a. The meals should be light, very moderate in quantity, at reg- ular and not too long intervals between each. In the plethoric and more acute states, animal food should be altogether or nearly relinquished; but in the asthenic conditions, or when there ap- pears to be a deficiency of blood, the more di- gestible kinds of animal food may be allowed once, and occasionally twice, a day. Even in these latter cases, a spare, but nutritious and digestible, diet ought to be adopted, as a liberal allowance will seldom be duly assimilated, and will only embarrass the digestive organs.. The principal meal should be taken early, and a light supper, consisting of a biscuit and half a pint of milk, about an hour before retiring to rest. The only drink, in plethoric habits, should be water, or toast-water, or imperial; but in the opposite states, and in asthenic cases, Seltzer water, or even Pyrmont or Spa waters, with milk, may be allowed. Chocolate and cocoa are unsuited to the former class of cases; and coffee and green tea should be avoided, especially where active deter- mination to the head is observed. Black tea once a day, and milk and water, are the best suited to the ordinary states of the disease. Not more than half a pint of any liquid should be taken at one time. 114. b. Epileptics should not, sleep longer than seven hours. They ought to lb in an airy chamber, without curtains to the bed, and with- out night-caps ; upon a hair mattress, with the head and shoulders somewhat raised. The hair ought to be worn closely cut, and in the severe sthenic cases should be shaved entirely off. The tepid or cold affusion on the head, or shower bath, should be used every morning, the scalp being afterwards well rubbed. In all cases, early rising, and regular exerdse in the open air, should be enjoined. But the exercise should not be at one time, but twice or thrice daily, with intervals of repose. It should be taken on foot, and not sooner than two hours after a full meal. The patient should be as much as possible in the open air; but should not venture on horseback. Flannel ought to be worn next the skin, and the lower extremities constantly kept warm. During warm weather, a light-coloured hat should be worn ; and ex- EPILEPSi—Bibliography and References. g 15 posure to the sun's rays always avoided. When the attacks are at all frequent, the patient ought never to be without an attendant, and he should be guard- ed from the fire, from precipices and water. He ought not to frequent crowded assemblies, nor even the bustling and crowded streets of great cities, nor should he look down from precipitous places. — There is no disease that requires a more strict dom- inance of the passions and desires than this. The concluding injunctions of M. Borie's judicious treatment (see note to § 104.) especially require observance, as the habits there referred to have a powerful influence both in inducing and perpetuat- ing the malady, and in destroying the constitutional and intellectual powers. Biblioo. and Refer.—Herodotus, 1. vi. cap. 84.— Hippocrates, De Morho Sacro, edit. Van der Linden, vol. ii. p. 324.; et De Aere Locis, et Aquis, vol. i. p. 327.— Aristotle, Probl. sect. xxx. quaest. i.—Aulus Gellius, Noct. Attic. 1. xx. cap. 1.— Aretaus, De Caus. et Sign. Morb. Acut. 1. i. cap. 4. et 5.; et Chron. 1. i. cap. 4. (The beet writer on epilepsy among the ancients.)—Celsus, 1. ii. cap. 8., et I. iii. cap. 23.—Galen, Comment, in Lib. vi. Epidem. j et Charter, t. ix. p. 550.—Calius Aurelianus, Chron. Morb. I. i. cap. 4.—Oribasius, Synopsis, I. viii. cap. 3, 4.—Aetius, Tetrab. ii. serm. 2.—Alexander Trallianus, 1. i. c. 21.— Paulus JEgineta, 1. iii. cap. 13.—Avicenna, Canon. I. iii. fen. i. tr. 5. cap. 8, 9.—Arnaldus de Villa Nova, Opera, fol. 310.—Roth, De Ortu et Cura Morbi Comilialis. Lips. 1548.—Mercurialis, Consil. vol. i. No. 26. 54. 77., vol. ii. No.85., vol. iv. No. 30. 56.—Gabuccini,De Morbo Comitiali. Venet. 1568.—Licbault, Ergo Ingeniosi et Libidinosi Epilep. Obnoxiosi sunt, 4to. Paris, 1580.—Bartholin, Hist. Anat. cent. iii. No. 80.—Deckers, De Epil. Adultorum, 4to. 1611. —Fernelius, Consilici, vii. et seq. ; et Patholog. 1. v. cap. 3. —A Collection of English Medicines experiencd against the Jaundice, Dropsy, Falling hickness, and Pestilence. Lond. 1615.—Forestus, Observat. I. x. No. 58.—Salmuth, Observ. cent. i. obs. 90.—Panaiolus, Pentecost, iv. observ. 42. 47., pt v. obs. 35.—Riverius. Prax. Med. cap. 7. ; et Obscr. cent. ii. No. 93.—Rolfinck, De Epil. 4to. Jenae, 1640.—Schel- hammer, De Epilepsia. Jenae, 1644.—Willis, Pathologia Cerebri. Oxon. 1664.; et He Morbis Convulsivis. cap. 3.— Pisi, De Morbis ex Serosa Colluvie, &.C. p. 100. 150.— Horstius, Opera, iii. p. 32.—Langlois, Ergo Epil et Me- lanch. Hapmorrhoidei Salutares. Paris. 1640.—Ettmiillei; Opera, vol. ii. par. ii. p. 779.—Sennert, 1. i.—Schenk, Obser. Med. Uarior. kc 1. i.—Wedel, De Epil. Hysterica. Jenae, 1676.— Ramazzini,Opera,p.339.—Tilemann,De Epil. Hy- pochon.,4to. Lugd. Bat. 1677.— Richard, Ergo Epil. Vena- rum Jugular. Sectio, -Ito. Paris, 16S9.—T. Mayerne, Prax. Med. kc. p. 52.—A. Bra,Catalogus Medicam. adversus Epil. Arnh. 1690.—Gould, in Philosoph. Trans. 1684. p. 537.— Eickmeyer, De Epil. Uterina, 4to. Ultraj. 1698 —F. Hoff- mann, Diss, sistens Aflectus Haereditarios. Halae, 1699.; et De Vera Mali Epil. Causa. Hal*, 1732.; et De Peregrina tionibus, kc Halae, 1701, p. 22.—Kriegel, De Epil. Rota- toria. Lugd. Bat. 1722.—Marchanl, in Mem. de l'Acad. des Scien. 1700, p. 355.—Cole, Consil. ^tiolog. de Casu quodam Epil. kc 8vo. Lond. 1702.—Clossy, Observations taken of Morbid Bodies, sect. i. obs. 9.—Bonet, Sepulchretum, 1. i. sect, xii.—Alberti, De Epil. 4to. Halae, 1718.—Boerhaave, De Morbis Nervorum, p. 770.—Van der Wiel, De Epil. Lugd. Bat. 1719.—J. Co/batch, Pi«. concerning Miseltoe, a most wonderful Specifick Remedy for Convulsive Distem- pers, 8vo. Lond. 1723.—Stahl, I.'e Morbo Caduco. Erf 1730.—Mead, De Imperio Soliset Lunae, cap. 2.—Mo.-gag- ni. De Sed. et Caus. Morb. ep. ix.—Millurs, De Medicam. Antepileplicis. Argent.1737.—Monro, in Edin. Med. Essays, &c. vol. v. part ii. p. 561.—Meibom, De Epil. Stomachica; 4to. Ilelmst. 1740.—J. Juncker, De Cur. Epil. sine Spe cificis, 4to. Halae, 1740.—Roncalli, Histor. Morborum kc.. p. 21. et seq.— Buchwald, Analysis Visci ejusque in Divers. Morbis Usus. Hafn. 1753.—Weisnvinn, in Nova Acta Nat. Cur. vol. i. p. 276.—Linnaus, Amcenit. Acad. v< I. ii. p. 135. —Kampfer, Amoen. Kxot. fasc. iii. p. 595. (Moxas along the coronal suture.)—Delius, De Cranii Ustione in Epil. Erl. 1763.—Locher. Observ. Pract. circa Lueui Ven. Epi- leps. et Maniam, 8vo. Vind. 1763.—H/innes, De Epil. Foliis Aur.intiorum Cur. kc. Leip. 1766.—Gesner, Beobacht. b. i. No. 19.—Andree, Cases of Epil. Hysteric Fits. kc. 8vo. Lond. 1764.—Van Swieten, Comment, kc. t. iii. p. 404.— Stoerck, Libel, de Stramouio, Hyoscyamo, kc f!vo. Vindob. 1762.—Mangold, De Epil. Speciebus nonnullis, in Opusc. Med. Phys. Alt. 1769.—Sauvages, Nosol. Method, t. ii. par. ii. p. 97.—Tralles. De Usu Opii, sect, iii.—Tissot, Traite de l'Epilepsie, 8vo. Lausanne, 1770.—Fothergill, in Med. Observ. and Inquiries, vo). vi. p. 79.—Johnston, in Ibid. vol. ii. No. 6.—Stall, Pradect. vol. ii. p. 1.—Haller Opuscula Pathol, obs. 74.—Werlhof, Opera Med. pars i. p. 88.—Baiter, Med Trans, of Coll. of Phys. vol. ii. p. 442.— D. Lijsons, Pracl. Essays on Intermit. Fevers, Dropsy, Epilepsy ice. 8vo. Bath,"l772.—Sidrcn, De Usu Slramoni) in Convuls. Ups. 1772.—Bromfteld, Observations and ases, vol. i. Lond. 1773.—JT. Threlful, E,»ay on Epilepsy, &c. 8vo. Lond. 1772.—De Haen, Rat. .Med. par. v. cap. 4.— Lieutaud, Hist Anat. Med. 1. iii. obs. 18. 50.—Thilenius, Med. u. Chir. Bemerk. p. 124.—Reininger, Diss, de Prole Parcntum Culpas luente. Lips. 1772.—Kinneir, New Es- say* on the Nerves, p. 117.—Crell, De Zinco Medico. Helms. 17S0.—Quarin, Animadvers. Practicae in Divers. Morbos. Vindob. 1726.—Weizenbreyer, De CuproMedicato. Erf. 1783.—Starke, Klin. Institut. p. 176.—W. Perfect, Cases of Insanity, Epilepsy, kc 8vo. Lond. 1781.—Hart mann, Diss, sstens varias Epil. Med. Methodos. Franc. 1787. —Greding, Vermischle Sehriflen, Ih. i. p. 2^)9. et seq.; et Sammtl. Schrift. i. p. 294. et seq.; et in Ludwig's Adver- saria, t. ii. et t. iii.—J. H. Miinh, Observ. Prat, de Usu Belladonna; in Melancholia, Mania, et Epil. 8vo. Goet. 1783. —Hirschel, Gedanken von der Fallenden Sucht, p. 35.— Feuerstein, De Epil. 4to. Goet 1792.—Michaelis, Med. Pract. Biblioth. b. I. st. 3.—Obertevffer, in Museum d. Heilk. b. iv. p. 172.—Theussink, in Ibid. b. iii. p. 147.—Wagner, Epist. de Morb. Insanabilium Curatione. Lips. 1792.—Bur serius, Institut. Med. Pract. vol. iii. p. 253.—Thomas, Journ. de Medecine, t. xxvii. p. 238. -Rochard, in Ibid. t. xxv. p. 46.—Chevulier, in Ibid. t. xii. p. 329.—Wienmann, in Ibid. t. xi. p. -ll.—Bouteille. in Ibid. t. xlviii. p. 544. —Lemonier, in Ibi I. I. lix. p. 421.—Arnaud, in Ibid. t. lxxvi. p. 246.—Beaumes, in Ibid. t. Ixx. p. 290. —Morand, in Ibid t. xxxv. p. 565.—De la Roche, in Ibid. t. xiii. p. 518.—Dumas, in Ibid. Dec. 1810, p. 385.—Ludwig, De Vi Terroris in Corp. Human, kc Lips. 1790.—Osiander, Denkwiirdigkeiten, kc b. ii. p. 188.—Ferriur, Med. Hist. and Reflect, vol ii. p. 4R.— Burmeister, De Morbo Spastico. Goet. 1791.—Piderit, Practische Annalen, st. i. p. 91.— Co/lingwood, in Edin. Med. Comment, vol. xviii. p. 390.— Heysham, in Ibid. vol. vii p. 349.—T. Bland, in Ibid. vol. vii. p. 301.—B. Bell, in Ibid. vol. i. p. 204.—De la Roche, in Ibid. vol. i. p. 200.—T. Percival, in Ibid, vol ii. p. 309., vol. v. p. 166.—Walker, in Ihid. vol. X. p. 288.—Guthrie, in Annals of Med. vol. iv. p. 473.—Mossmann, in Ibid. vol. ii. p. 413.—Cappe, in Ihid. vol. iii. p. 455 —Hull, in Ibid. vol. v. p. 2i5.—H ndcl, in Ibid. vol. iv. p. 213.—W. Batty, in Ibid. vol. vi. p 377.—Richter, Med. u. Chirurg. Bemerk. &c. p. 137.—Maissonneuze, Recherches et Observ. sur l'Epil. 8vo. Paris, 1800.—Currie. Mem. of Med. Soc. of Lond. vol. iv. art. 2.—Sims, in Ibid vol. iv. art. 24. et vol. vi. art. 29.—Stein, De Faba Sancti Ignatii. Erl. 1793.-^4. F. Hecker, Diss, de Epil. 8vo. Erf. 1800.— Portal. Mem. sur la Nat. et le Traitcment de plus. Mai. t. ii. p. 229.; et Observations sur la Nat. et le Traitem. de l'Epil. 8vo. Par. 1827.—Pinel. Nosographie Philosoph. vol. ii. p. 70.—Bos- tock, Med. and Phys. Journ. 1800, vol. i. p. 169.—Mage - nis, in Ibid. vol. iv. p. 417.—Arnemann, in Ibid, vol xiv. p. 430.—Willich, in Ibid. vol. i. p. 183. (Rev. of Med. successfully employed in epil.)—White, in Ibid. vol. ii. p. 173.—Rush, in Ibid. vol. xiv. p. 10.—Spence, in Ibid. vol. xviii. p. 355.—Fraser, Treatise on Epil. and the Use of the Viscus Quercinus, kc. 8vo. Lond. 1806. —Lentin, in Hufe- land's Journ. der Pr. Heilk. b. xiv. st. i. p. 44.—Hi/den- brand, in Ibid. b. ix. st. iv. p. 34., b. >iii. st. i. p. 140.— Joerdens, in Ibid. b. xiii. st. iv. p. 143.—Fischer, in Ibid. b. xii. st. i. p. 169.—Gebel. in Ibid. b. vii. st. iii. p. 177.— Muller, in Ibid. b. xx. st. i. p HS.—Bischoff in Ibid. b. xxx. st. ii. p. 126.—Hufeland, in Ibid. June, 1811, p. 14.— Renter, in Ibid. b. xvii. st. i. p. 113.— Autenrielh, Physiol- ogie, § 1(141. (The medulla oblongata diseased.)—Baldin- ger, Magazin fur Aerzte, st. iii. p. 745.—Vieweg, Annalen der Heilkunst, Mav, 1811, p. 426.— Prost, Med. Eclairee par l'Obsenat. et l'Ouvert. de Corps. 8vo. vol. ii. p. 379. j Paris, 1804.—Joseph Frank, Acta Institut. Clin. Universit. I Vilnens. \c. Lips. 1808.; et Praxeos Med. Uuiversa Prae- | cepta, pars ii. vol i. sec. ii. p. 277.—/. Wenzel, Beobacht ' iiber den Hernauhang Fallsiichtiger Personen, kc 8vo Mainz. 1810.—Esquirol, in Diet, des Sciences Medicales, t. xii. p. 510.—Powell, Med. Trans, of Coll. of Phys. vol. iv. art. 8. — Badeley, in Trans, of Med. and Chirurg. Soc. vol. ix. | p, l.—Valentin, Ann. de la Soc. de Med. de Montp. t. viii. par. ii. p. 301. (Superacetate of lead in epil.)—L6benstein- Lbbel. Weien u. Heilung der Epilepsie, 8vo. Leip. 1818.— Albers, iu Med.-Chirurg. Soc. Trans, vol. vii. par. i.—Roget, in Ibid. vol. vii. p. 290.—Halle, in Nouv. Journ. de Med. t. v. p. 185.__liudotphi, Diss, sistens Casum Epil. per Ter- ebrationem Cranii Sanatae, 8vo. Berol. 1811.—Moreau, I Recueil Periodique, kc. t. vi. p. 226.—Cullerier, in Ibid. t. xiv. p. 271.—J- C. Prichard, Treat, on Dis. of the Ner- vous System, 8vo. Lond. 1822, p. 85. et seq.—M. Geor- get, La Physiol, du Syst. Nerveux, et Recherches sur les i Mai. Nerveuses, t. ii. p. 365. Paris, 1821.; et Diction, de 1 Med. t. viii. p. 206.— J. Cooke, Hist, ofthe Method of Cure 816 nir-tTILE TISSUE— ERETHISM. of the various Species of Epil. 8vo. Lond. 1823.—Larrey, Rev. Medicale, Jul. 1822. (The s>philitir.)—Menard, in Ibid. Mars 18-5.—D. A. G. Richte,, l>ic Specielle Thcr- apie kc b. vii. p. 552.—Mills, The Morb. Appearances in Dis. of the Brain, kc Dub. 18^6, 8vo. p. 213.—Chisholm, in Lond. Med. Re os. vol. xxi. p. 192.—Carter, in Ibid. p. 369. — Burdach, Archives Gtner. de Med. t. vii. p. 588. (Cases treated by the artemisia.)—Boileau, in Ibid. t. viii. p. 45. (Case where ligature nf carotid f r a wound did not effect a permunent cure.)—Masseau, in Ibid. t. viii. p. 603. (Case in which the heart was remarkably small.)—Peysson, in Ibid. vol. xi. p. 462.—W. Shearman, Lond. Med. and Phys. Journ. vol. xxiii. p. 314.; and Lond. Med. Repos. vol. xviii. p. 181.—J. Smith, in Lond. Med. Repos. vol. iv. p. 191.—Sweeting, in Ibid. vol. v. p. 175—R. Reid, in Transact, of Collet of Phys. in Ireland, vol. iv. p. 354.— Creighton in Ibid. vol. iv. p. 332.—Gunn, in Edin. Med. and . urg. Journ. No. 90. p. 78.—ScM, in Ibid. No. 90. p. 19.—Willi ms, in Ibid. No. 85. p. 297.—Coutes, in Ibid. vol. i. p. 428.—Clarke, in Ibid. vol. v. p. 272.—Lithgow, in Ibid. vol. xi. p. 300.—Prichard, in Ibid. vol. xi. p. 458.— E. Percival. in Ibid. vol. ix. p. 271. ; and Dub. Hosp. Rep. kc vol. i.—Lombard, Gazette Medicale, No. 66. vol. iii.— W Burnett, Trans, of Med. and Chirurg. Soc. vol. xiii. p. 202.—Tacheron, Recherches Anat. Pathol, sur la Med. Prat. t. iii. p. 526. Paris, 1823.—Rogers, New York Med. and Phys. Journ. 1826.—L.F. Calmiel, L'Epilepsie etudiee sous le Rapp rt de son Seige, 8'vo. Paris, 1826.—Baillie, Lectures and Observations on Medicine, 8vo. Lond. 1825.— Revue Med cale, t. iii. 1827.—Menard, in Ibid. t. i. 1825 p. 388.—Brofferio, in Ibid. I. iv. 1825, p. 488.—Larrey, in Ibid. July, 1822.; et Med. Chir. Rev. vol. iv. p. 465.— Kolowitch, Journ. des Progres des Sciences Med. t. xii. p. 257.—Bouchet et Cazauviei/h, Archives G^nerales de Med. t. ix. p. 510., et t. x. p. 5. (Relations of epil. with insanity.) —Loewenhard, in Ibid. vol. xvi. p. 606.—Urban, in Ibid. t. xvi. p. 273.—Stengel, in Ibid. t. xvi. p. 597.—Rennes, in Ihid. t. xvii. p. 63.—F. Hatin, De l'Epil. consid. dans sa Nat. et ''ans ses Causes et des Moyens prop, a les querir, 8vo. Paris, 1830.—Elliotson, in Lancet, vol. xviii. p. 116. 231. 539. ; and in Lond. Med. Gazette vol. vii. p. 423. 798., vol. vi.i. p. 278., and vol. xi. p. 577. 609.—Sims, in Ibid. vol. vii. p. 374.—,4. T. Thomson, in Ibid. vol. ix. p. 241. 387.—F. Hawkins, in Ibid. vol. viii. p. 183.—Davidson, in Ibid. vol. ix. p. 664.707. 819.—Roots, in Lond. Med. and Surg. Journ. vol. iii. p. 12. 171.—Boisseau, Nosographie Organique, t. iv. p !S2.—Foville, Diet, de Med. et Chirurg. Prat. t. vii. p. 412. — Cheyne, in Cyclop, of Pract. Med. vol. ii. p. 85.— Burtels, Encyclop. Worterb. de Medicin. Wissenchaften, b. xi. p 357.—Andral, Lectures on Epil. in Lancet, No. 502. p. 65., and No. 503. p. 102. EPISTAXIS. See Hemorrhages. ERECTILE TISSUE. — Syn. Vasa Erigenlia; Tela Erectilis. Tissue Erectile, Fr. Erectiles Gewebe, Ger. Classif.— Pathology — Morbid Struc- tures. 1. This structure, which is eminently vascular, and copiously supplied with organic or ganglial nerves, possesses, beyond all others, that vital property which is obscurely evinced by several other textures, and which was denominated the turgor vitalis, or vital turgescence, by Heben- striet, Schlosser, Reil, and Ackermann. This property, whether denominated as above, or called vital expansion, or any other name, is more generally diffused, and presents more important relations, both in health and in disease, than has usually been acknowledged. The reader will find it more fully discussed under the article Turges- cence. I have merely to notice in this place, very briefly, the morbid states, which the parts allowedly erectile present. These parts are — the cavernous and spongy body of the penis, as well as its bulb and gland; the clitoris and nymphae ; and the nipple of the female. There are other parts more obscurely (owing to their situation), but undoubtedly, endowed with this property : these are—the uterus, especially its neck; the Fallopian tubes, particularly the fimbriated ex- tremities ; the spleen; and the lips of both sexes: but these are not comprised in the following ob- servations. The morbid structure called Neevus Maternus, Aneurism by Anastomosis (Bell and Freer), Angiectasia, or vasorum dilatatio (Meckel), Telangiectasis,or vasorum uttimorum distensio, by some German authors, appears to be merely an accessory or morbid form of the erec- tile tissue; and 1 agree with Dr. Craigie, in con- sidering that such is the case, and that the throb- bing vascular tumour first noticed by Pearson, and subsequently minutely described by Scarpa, is an adventitious formation of the same kind. 2. The erectile tissue may evince its charac- teristic property in a very marked manner, and to an extent that is truly morbid, without any appre- ciable change in its organisation. This is shown in priapism, in which the vascular turgescence is the result merely of nervous excitement or irri- tation. Chordee is a modification of this state, caused chiefly by inflammation of an adjoin- ing structure; the erectile tissue of the penis being excited, whilst the submucous tissue of the urethra is inflamed, and unyielding, owing to its morbid state, and to spasm of the ischiocaverno- sus muscle. 3. Hamorrhage rarely takes place spontane- ously in erectile tissues. I have, however, met with it in the corpus cavernosum of the penis, occasioning a state nearly resembling that of pri- apism, but unattended by nervous or mental ex- citement. In this case, the morbid state was re- moved by a small incision made into the cavern- ous structure, when grumous dark blood escaped. An interesting instance of this kind is recorded by Mr. Callaway. Similar changes are not so infrequent, from external violence, particularly in the erectile tissue of the female organs, owing to difficult or instrumental labours. 1 his tissue may be the seat of excrescences, of scirrhus, and, like others, be involved in specific inflammation, malig- nant ulcerations, and adventitious formations ; but such of these, which belong to the province of the physician, are noticed in the articles on the Spleen and Uterus. Biblioo. and Refer.—J. Bell, Principles of Surgery, kc. vol. i. disc. xi. p. 456. 1(01.—Freer, On Aneurism and some Diseases of the Arterial System, kc Birm. 1S07.— Pearson, in Med. Coininunica. vol. ii. p. 95.—Scarpa, On the Pathology and Treat, of Aneurism.—Callaway, in Lond. Med. Repos. vol. xxi. p. 286.—Craigie. General and Patho- logical Anat. p. 192.—Meckel, Anat. Pathol, t. iii. p. 792.— Beg-in, in Diet de Med. et Chir. Prat. t. vii. p. 440.—Mul- ler, Encycl. Worterb. der Med. Wissenschaft. b. • i. p. II0. ERETHISM, and MERCURIAL ERETHISM. Erethismus (.nediau'u; from t(JEt)iL>, I excite or irritate.). 1. I. Erethism, in Pathology, has been gen- erally understood, since the time of Hippocra- tes, as implying a state of irritation, or excite- ment of a part, different from, or short of, the in- flammatory condition; although often passing into it. Hippocrates and Areta;us viewed it as irritation, accompanied with some degree of debil- ity. Galen applied the term to irritation of the 1 stomach and intestines by acrimonious fluids; and most of the ancients believed that, where it 1 existed, it prevented the accession of salutary critical evacuations. Many modern pathologists I employ it as synonymous with orgasm, or simply | an exalted state of the vital actions of a part ; I and others attribute to it more of a morbid im- ! port, viewing it as an early stage, and lesser grade, of many acute diseases, especially those i that are febrile or inflammatory. The most fa- - miliar illustration of this state, according to the ERETHISM, MERCURIAL. —ERGOTISM. 817 former class, is the act of blushing. According to the latter class, the ravenous appetite attend- ant sometimes upon debility and various affec- tions of the digestive organs, proceeds from erethism of these parts, or, in other words, from an excited state of the nerves of the organ, with increased circulation and secretion or exhalation from the villous surface. It is very probable, that this state, either prolonged, or frequently exci- ted, will give rise to acute or chronic inflamma- tion, and even to changes of structure, and to effusion from mucous or serous surfaces. That it prevents the accession of critical changes, is also probable. 2. This condition should be viewed as morbid, and treated according to its seat and grade. It requires, generally, refrigerants, light or low di- et, soothing and mucilaginous drinks, tepid or warm bathing, cooling diaphoretics and diuretics, and mild laxatives and enemata. When neg- lected, it is apt to extend the sphere of its mor- bid influence, more especially when seated in the digestive mucous surfaces; the functions of di- gestion, sanguifaction, and assimilation becoming disordered, and irritation supervening in the cuta- neous surface, in the liver, and even in various remote parts. (See art. Disease, § 72. et seq. and 78. et seq.) 3. II. Erethism,Mercurial—Erethismus Mercurialis—was the name given by Mr. Pear- son to that extreme state of irritability and ex- haustion which sometimes is occasioned by mer- cury. Before this state was described by this surgeon, its nature and cause had been entirely overlooked, although it must have often occurred, and even proved fatal. It evidently arises from the poisonous action of the preparations of mer- cury upon the organic nervous system and heart. The preparations which most commonly produce it, are, the blue pill and the ointment, particu- larly the latter; and it is not improbable that some change may take place in these from the action of the air, when they have been long kept, that will give rise to this affection, if they be pre- scribed in the quantities safely administered in the more recent state. A mercurial atmosphere, as in confined syphilitic wards, has also, very prob- ably, a considerable share in its causation. The erethismal symptoms usually come on early in a mercurial course, but they may occur at any pe- riod. When once produced, they very readily re- turn upon resuming the mercury, in the same form that first occasioned them. Pre-existing debility, the action of malaria, the scrofulous diathesis, con- stitutional susceptibility and irritability, and pre- vious mental excitement and anxiety, seem to be, as far as is yet known, the chief predisposing causes. 4. i. This affection usually commences with slight trembling of the limbs and tongue, sense of fluttering in the chest, irregularity of the heart's action, and palpitations on the least exertion. The pulse is feeble, small, quick, compressible, irregular, or intermitting. The strength is ex- tremely depressed, the countenance is pale and contracted ; and great anxiety at the praecordia, with frequent sighing and a feeling of sinking, is complained of. If the mercury be still con- tinued, the tremblings, the frequency, irregulari- ty, and intermissions of the pulse, increase rap- idly, and are attended by a sense of coldness, and 69 sometimes by vomitings. At this period, sudden or great exertion may extinguish life. 5. ii. The Treatment, early in the affection, is generally easy and effectual. Upon the first in- dication of it, the patient should be removed to, and remain as much as possible in, the open air; and mercury, in every form, relinquished; even a mercurial atmosphere should be avoided. The pre- parations of ammonia and camphor ought to be given in "full doses, and the surface of the body cleansed from all impurities, especially from the remains of mercurial ointment. Having thereby restored the state of the circulation, a course of nitric acid with sarsaparilla should be entered upon, and the bowels kept gently open by a suffi- cient dose, of the precipitated" sulphur taken at bedtime on alternate nights. If it should be still necessary to resume the use of mercury, as some- times proves to be the case, the utmost circum- spection is requisite. The oxymuriate, in the tinc- ture of cinchona, or in the form of pill with the pulvis glycyrrhiza3 and camphor, and taken with the meals, will often produce a sufficient saliva- tion. After a most severe case of this affection which came under my care, where it was deter- mined, in consultation, to have recourse to mer- curial salivation as a last resource, for the cure of most dangerous secondary syphilis, the pre- paration prescribed in the manner now men- tioned had the desired effect. BlBLIO ;. and Refer.—Hippocrutes, Aphorism, xx. sect. i.—Aretaus, De L'ur. Hub. Acut. I. i. cap. 1.—J.Pearson, On the Lues Venerea, 2d edi'. p. 156.—Vaidy, in Diet, des Scien. Med. t. xiii. p. 161.—Bateman, Trans, of Med. and Chirurg. Soc. vol. ix. p. 220.— T. H. Burder, in Cyclop. of Pract. Med. vol. ii. p. 104. ERGOTISM.—(Classif. Pathology,^Eti- ology.) Diseased, unripe, or damaged grain of any kind, is injurious to the animal economy, ac- cording to the quantity consumed. The species of grain, the nature of its alteration from the wholesome state, and the proportion of it enter- ing into the food of man and the lower animals, are the chief circumstances modifying the morbid results. Rye is most frequently productive of in- jurious effects in the northern countries of Eu- rope, the disease in it giving rise to the ergot, or spur, being the chief cause. But wheat, rice, or any other grain, either similarly diseased, or pre- maturely cut down, or damaged by the mode of keeping, or by age, or mixed with the seeds of poisonous plants, as those ofthe Raphaniarapha- nistrum and the Lolium temulentum, will occasion dangerous diseases. The noxious effects of spur- red rye (Secale cornutum) have been most fre- quently observed, and are especially noticed in connection with the affections of which it is one of the chief causes. (See arts. Gangrene, and Spasm — Cachectic.) But the disorders produ- ced by other kinds of diseased or unwholesome grain, are in many respects similar to those con- sequent upon the use of spurred rye. Sufficient allusion has been made, in the article Epidem- ics, to the influence of unripe, blighted, defi- cient, or damaged crops, upon the health of the community; the epidemics thereby occa- sioned, varying in character with the particular state on which the unwholesomeness of the grain depended, and the concomitance of other causes. The particular unwholesome condition of grain has not, however, been hitherto viewed suf- ficiently in connection with its specific effects 818 ERYSIPELAS — General Description. upon the economy, in any one instance; and it is only in respect of spurred rye, that we have any kind of data that will admit of the special consideration of the subject. From some cir- cumstances that have come before me, I should infer that unripe grain is productive chiefly of diarrhcea and dysentery; that diseased, impure, or blighted grain, most frequently occasions affec- tions of the nervous and vascular systems, with disorder of the digestive organs, and contami- nation of the circulating fluids; and that damaged and old grain gives rise principally to fevers of a malignant or adynamic kind, with predominance of some one or more of the preceding affections, according to concurrent causes and circumstances. (See Disease — Causation of; Gangrene, and Spasm.) ERYSIPELAS. Syn. — 'E/riy Wyioiia, Hippo- crates ; ifivaintXag, Gr. (from naqa to ini'eaPai tni to niXu:, that it extends to ad- joining parts; or, rather, from ini'i-, I draw, and 7ii).uc, adjoining; or from ioifi^u.-, red, and m/.bc, brown, livid) Ignis Sacer, Lat. Febris Erysipelatosa, Sydenham, Schroeder, &c. Fe- bris Erysipelacea, Hoffmann, Vogel, &c. Rosa, Sennert. Ignis Sancti Antonii, Auct. Var. Emphlysis Erysipelas, Good. Erysipcle, Fr. Die Rose, der Rothlauf, Germ. Erisipela, Ri- sipola, Ital. The Rose, St. Anthony's Fire. Classif. — 1. Class, Febrile Diseases; 3. Order, Eruptive Diseases (Cullen). 3. Class, Sanguineous Diseases ; 3. Order, Eruptive Fevers (Good). 4. Order, Vesicular Erup- tions (Willan). III. Class, III. Older (Author, in Preface). 1. Defin. — Asthenic inflammation of the in- teguments, affecting them more or less deeply and extensively, with diffused tumefaction, and a dis- position to spread, depending upon constitutional disorder. 2. I. General Description. — A. Ery- sipelas* usually commences with either the local or the constitutional symptoms more prominently marked; but I believe that the local symptoms never manifest themselves before some disorder referrible to the vital sources and centres has been present, although frequently in too slight a degree to alarm the patient or come before the physician. Previous to, or accompanying, a sense of tension, itching, heat, weight, and un- easiness, with diffused redness and swelling of the skin, the patient experiences chills, rigors, dis- turbance of the functions of the stomach and bowels, and a quickened circulation. On the second and third days, the swelling, which was either slight, or scarcely noticed, increases ra- pidly, extends superficially, and is warm, shining, of a yellowish red colour, disappearing moment- arily during pressure, with a tensive burning pain, exacerbation of fever towards evening, and re- missions in the morning. In addition to these, the patient complains of frontal headach, drowsiness, * Some confusion has arisen from the manner in which this disease and erythema have been viewed in relation to each other, and in which both have been classed. For, while I admit, with Dr. GOOD, that the term erysipelas has been loosely employed in medical writings, yet I conceive that it will not add to the precision of our knowledge to remove certain of the varieties of erysipelas to the genus erythema, where their local characters are chiefly considered, and their more important constitutional and vita) relations are over- looked. anxiety at the pra:cordia, general lassitude, and pain or aching of the limbs; anorexia, nausea, or vomiting; thirst, and heat or dryness of skin. The tongue is generally loaded, and subsequently dry; the bowels are constipated, and the motions offensive; the urine is turbid or saffron-coloured; and the pulse full, soft, frequent, sometimes broad and compressible, and often oppressed or irreg- ular. The disease generally runs its course, in its more acute forms, between the seventh and fifteenth day. It is sometimes extended to the twenty-first, but seldom beyond, unless in cases of relapse or metastasis, or when it assumes certain anomalous forms, or occasions organic changes of subjacent or internal parts, which pro- long the fever and increase the danger. 3. B. Erysipelas presents phenomena which are peculiar to it, and distinguish it from phleg- monous inflammation, on the one hand, and from the inflammatory action attendant on rheumatism and catarrh, on the other. — a. The characters of erysipelatous inflammation are as follow : — a. The pain is peculiar — is tensive, burning, or stinging; is not severe, but is diffused throughout the inflamed surface, and is occasionally remit- ting. — /■?. The redness is not intense, as in phleg- mon; but is either pale, rose-coloured, or of a pale yellowish hue — arising, seemingly, from a more copious and diffuse deposition of serum, slightly tinged with a little blood. The redness always disappears on pressure, but quickly re- turns when pressure is removed: it is of a deeper red when the attendant febrile action is of a sthe- nic kind; and of a more livid hue when the vital powers are much reduced.— /. Tumefaction is always present, and is sometimes very remarka- ble, owing to the effusion of serum into the sub- cutaneous cellular tissue. It is, however," diffused, never acuminated or convex; but sometimes hard or brawny, as in the sthenic or phlogistic vari- ety ; and occasionally soft and boggy, ns in the oedematous or asthenic variety, or when the ad- jacent cellular tissue is affected or suppurating. 4. b. Erysipelas is seated chiefly in the integu- ments ; but it presents various modifications, according as the more superficial or more internal tissues of the skin are especially diseased. Where the cutis vera is the principal seat, the cellular tissue underneath is also materially affected; it being usually infiltrated with serum, tumefied, and sometimes inflamed to a very considerable depth in some instances; whilst the more superficial capillaries likewise partake in the disturbance.— Where, on the other hand, the rete mucosum and papillary tissue are the chief seat, the dis- ease is commonly accompanied with vesication. When this occurs, or when a discharge from the surface, or free exfoliation of the cuticle, takes place, the severe affection of the subjacent cellu- lar tissue very rarely is observed. 5. c. Erysipelatous inflammation has always a tendency to spread to adjoining, and occasionally even to attack remote, parts. As long as the me- tastasis, or vicarious affection of distant parts, is confined to the integuments, the primitive form and nature of erysipelas is retained; but, as soon as it has apparently attacked internal organs, which is sometimes the case, owing to their pre- existing disposition and morbid conditions, aud to the operation of superadded causes, then the af- fection of the skin disappears, and the super- ERYSIPELAS — Particular Description. 819 mduced internal disease occasions the symptoms of an idiopathic malady, with more or less of the constitutional disturbance characterising the erysi- pelatous eruption, particularly those which relate to the vital energies and powers of resistance. Thus, inflammations of internal parts, as of the serous or mucous surfaces, may displace, or be vicarious of, the erysipelatous disease ofthe skin; but such inflammations will still retain peculiar features, and differ from idiopathic or true phlo- gosis of those parts; the depression of the powers of life, the morbid condition ofthe circulating fluids and ofthe excretions, characterising erysipelas, at- tending also upon them, often in increased grades. 6. d. Like other inflammations of mem- branous parts, erysipelas generally assumes an acute form; and, in this respect, resembles phlegmon: but differs from it very materially as regards the nature of the constitutional disorder, especially the morbid state of the circulating fluids and of the excretions, and the manner of termination — particularly the slow convales- cence; the persistence of congestion — especially ofthe venous capillaries; the desquamation of the cuticle, and the tendency to relapse. 7. e. The characteristics of erysipelas arising from the texture in which it is seated, are — the dryness, the stinging heat, the peculiar shining appearance of the surface, the burning and itch- ing, and the frequent elevation of the cuticle into vesicles, or its successive desquamation. All these indicate— 1st, suppression of transpiration, with increased circulation; 2d, morbid sensibil- ity of the cutaneous nerves; 3d, a preternatural secretion of serum beneath the cuticle; and, 4th, an altered state of the reproductive or plastic function of the rete mucosum. 8. /. When erysipelas has once attacked the frame, there remains a certain morbid diathesis, disposing to renewed attacks at distant intervals. The same property is also evinced b^ several non-contagious affections ofthe skin; and is most probably owing to acquired constitutional dis- position, or rather, to a weakened state of the digestive and excreting or alimentary organs — to a latent state of disorder arising out of the remote causes of the disease, and heightened or rendered more persistent by its attack. 9. g-. The causes of this malady are fre- quently the same as those of low forms of fever, catarrh, and rheumatism; for, like them, it generally proceeds from peculiar states and vicis- situdes of weather and of the atmosphere; espe- cially cold, moist, miasmatous, and foul con- ditions of the air, acting upon a system already disposed to their influence by depression of vital power, or by the accumulation of morbid or effete matters in the circulation, owing to defec- tive action of the excreting organs, to unwhole- some diet and regimen, or to prolonged disorder ofthe prima via. 10. h. Erysipelas is generally preceded and ac- companied by more or less fever, according to the situation of the part affected, the sensibility and irritability ofthe system, and the character ofthe prevailing epidemic constitution. It should never be considered apart from the attendant state of con- stitutional disturbance, — from the manifestations of vital power, and the conditions of the cir- culating fluids, and secretions,—of all which the local affection is merely an extensive and im- 1 portant effect; but one which reacts upon these states and conditions, whence it chiefly derived its origin, or at least its peculiar characters. The modifications of the attendant fever depend chief- ly upon the constitution and pre-existing state of the assimilating and excreting organs, upon the prevailing epidemic influence, and upon the weather and season. Thus, the fever more commonly approaches the inflammatory type dur- ing cold and dry seasons, or in winter and spring; whilst the more adynamic forms, with predomi- nance either of the gastric, bilious, or nervous states, are most frequent in summer and autumn. 11. II. Particular Description.— Erysip- elas presents various modifications, according — 1st, to the part affected; 2d, to the nature and form ofthe local changes; 3d, to the states of constitution- al disturbance with which these changes are asso- ciated, and on which they are dependent; and, 4th, to the causes which have produced it. 12. ^4. Modifications as to the part affected.— The sensibility of the part in health, and its vital relations, especially modify the consentaneous disturbances of the sensiferous and vital functions generally characterising this malady. If it at- tack the face, commencing in one cheek, it gene- rally soon extends to the other; and in a short time to the forehead and scalp, producing more tumefaction than almost in any other situation, owing to the effusion of serum in the subcutaneous cellular tissue. The eyes are closed or prominent; the nose is distended; the ears are red, shining, and burning. On the second or third day, the whole head and face are often enormously distended, pre- senting a yellowish or sub-livid redness.—Also, when the disease commences in the scalp, owing to punctures, bruises, or contused wounds, the af- fection of the subcutaneous cellular tissue is very great, frequently followed by diffused suppuration, and disease of the fibrous tissues adjoining. But, whether originating in the face or in the scalp, the greater the extent and intensity of the affection of these parts, the more are the functions of the brain, of the circulation, and of secretion dis- turbed. Hence the violent headache, tinnitus au- rium, delirium, sopor, convulsions, coma, &c. ; the parched and dark tongue; the morbid state of the evacuations; and the disturbance of respira- tion. 13. When erysipelas attacks the face, it some- times affects the mouth and fauces, extending in some instances to the pharynx and larynx, inter- nally, and down the neck to the chest externally. An interesting case of this kind was attended lately by Mr. By am and myself, where the enor- mous tumefaction of the neck and throat, with the affection of the larynx and trachea, increased by the constriction produced by the integuments surrounding the neck and throat, caused suffo- cation in a few hours.—This extension of the disease to the fauces and throat, not infrequently occasions a species of consecutive croup, as stated in that article (§ 18. d.) : it may also occur, when the scalp is affected; but, in this case, the dis- ease generally extends down the neck and back, even to the loins. The disposition to spread thus extensively, and to affect subjacent parts, is most remarkable when the pulse is frequent, and vas- cular action greatly excited, at the same time that vital power is much depressed, the functions of excretion impeded, and the blood morbid. 820 ERY'SIPELAS — Particular Description. 14. In other parts of the body, the symptoms are generally not so severe. The pain, however, is very great when the disease attacks the mamma during lactation, or when it extends to the organs of generation. In these situations, it frequently implicates the subcutaneous cellular tissue and adjoining glands, and thus closely approximates in seat and nature to the primary form 0/ spread- ing inflammation of the cellular tissue. When it occurs in the latter situation, in children be- tween one and six years of age, it often proves fatal, either from this circumstance, or from sloughing ulceration. Where the extremities on- ly are affected, there are generally less pain and constitutional disturbance than in other cases. 15. B. Modifications of the local affection. — The changes which take place in the external seat of disease, may be classed under four varie- ties: the glabrous, vesicular, crustaceous, and deep-seated.— o. The glabrous local affection consists in a diffused or plane and smooth tume- faction of the skiu, of a rose or yellowish redness, sometimes verging to a sub-livid hue. — b. The vesicular form is attended with bullae, or blisters, in parts of the inflamed surface, resembling the 1 vesicles raised by cantharides. Sometimes they are numerous, small, and discrete phlyctena; at other times confluent, and forming very large bulla, containing a yellowish, sometimes dark, sanguineous, acrid serum, effused between the rete mucosum and cuticle, which it elevates. These vesicles continue to appear during the course of the disease; are accompanied by an un- pleasant tension, itching, burning, or pain; and, instead of diminishing, often increase, the inflam- mation and fever.—c. The crustaceous form arises from an early rupture of the cuticle, and escape of the lymphatic serum effused beneath it, which exposure to the air forms into crusts, and under which an acrid fluid collects, and irritates, or even ulcerates, the skin.—d. In the deep-seated and tumefied, the cellular and other subcutaneous tissues are affected, either by oedema, or by phlegmonous or diffusive inflammation, tending to disorganisation. Whilst the superficial parts of the integuments are the chief seat of the affec- tion, in the preceding varieties, the tissues under- neath are principally diseased in this, particularly the cellular and adipose; and they present every shade of morbid action, from simple passive oedema, to inordinate vascular excitement—from the lowest state of asthenia, to the highest degree of vital action — either passing rapidly into sup- puration, or into disorganisation, or spreading ex- tensively in the course of the cellular tissue, and involving other adjoining parts, as shown in the article on Diffusive Inflammation of this Tissue. It is generally observed in this associated or dee.;- seated malady, that the skin is but slightly al- tered, or that the morbid action in it diminishes, as that in the subjacent parts increase, especially if the latter be of a diffusive or septic kind. 16. C. Modifications connected with the con- stitutional disturbance.—The forms which the disease assumes, chiefly result from the states of the nervous system, of the assimilating and ex- creting organs, and of the circulating fluids, and from the temperament and habit of body. These modify the febrile action as well as the local af- fection, aided by the existing grades of consti- tutional power and vital resistance. Erysipelas consequently presents every intermediate shade between high vascular action with simply dimi- nished vital power, and low vascular action with great depression of the vital energies, as respects both the part chiefly diseased, and the system in general.—a. As soon as the morbid action in the skin passes a certain height, it generally ex- tends to the subjacent cellular tissue; and if it occur in young, robust, or plethoric subjects, or if the constitutional powers be not much re- duced, or the nervous system not materially ex- hausted or oppressed; or if the functions of the digestive and excreting organs be not altogether overpowered; then the disease assumes more or less of the sthenic or phlegmonous character, both as to its local appearance and the attendant fever, and has a marked tendency to pass into suppu- ration, occasionally with destruction of the sub- cutaneous cellular and adipose tissues.—6. When the disease is attended by signs of accumulated sordes in the prima via, with nausea and vomit- ing, and a morbid state of the secretions, par- ticularly of the biliary secretion,— characters which itoften presents,—it has received, from Con- tinental pathologists, the appellation of gastric or bilious erysipelas.— c. If it present great de- pression or disturbance, especially ofthe cerebro- spinal nervous functions, with a pale, evanescent, and changeable state of the part affected, and imperfect secretion and excretion; and if d - lirium coma, subsultus, &c. supervene; or if the local affection spreads rapidly, or if it entirely disappears, and is followed by internal disease; it has been called nervous erysipelas, or it may be said to be complicated with febrile disturbance of the nervous kind.— d. If, owing either to exces- sive morbid action over vital power, or to a faulty state ofthe system at the time of attack, orAvhen it supervenes upon remittent or continued fevers, or upon any cachectic malady, or in aged or broken-down constitutions, it extends to the sub- cutaneous structures, and gives rise to oedema, or terminate in softening or disorganisation of these parts, it has received the name of adematous, septic, or gangrenous erysipelas. This state of the malady is generally connected with defective assimilation and excretion, with an impure state of the circulating fluid, and with deficient vital power. 17. D. The causes which dispose to, or excite, the disease, have also great influence in modifying its characters, both local and general. When propagated by infection, it is prone to assume a complicated state, or to be associated with in- flammation of the throat and pharynx of a most dangerous character, owing to its disposition to spread to the larynx and trachea; and with dif- fuse and gangrenous inflammation of the subcuta- neous cellular tissue. A similar complication is also observed during certain epidemic constitutions, or when the disease has been occasioned by the contact of animal matters in a state of decom- position, or by other septic agents. In these cases, the tumefaction is often great; and, although vas- cular excitement may be very remarkable, vital power is much depressed, and speedily over- whelmed; owing chiefly to the morbid state ofthe circulating fluids, or to the contaminating and septic operation of these causes. 18. III. Division of Ervsipelas. — This disease has been divided by authors, according to its various states, into febrile and non-febrile ; ERYSIPELAS —Simple—Complicated. 821 the stationary and the erratic; the benign and malignant; the acute and chronic; the periodic or habitual, and the accidental; the sporalic and epidemic; the idiopathic and symptomatic; and the primary and secondary: to which may be added, the internal and external. As to all these general divisions, it is only necessary to remark that, by Idiopathic erysipelas is understood that condition of the disease which arises from the direct impression of the causes on the skin, as from vicissitudes and epidemic states of the air, chemical stimuli, morbid effluvia, poisonous mat- ters, &c; and by Symptomatic, is meant the ex- ternal manifestation of internal disorder, as of impeded secretion and excretion, the accumu- lation of morbid excretions in the prima via, and an- impure state of the circulating fluid, either from interrupted elimination of effete matters, or from the absorption of morbid matters. As to the existence of Internal erysipelas, I may observe, that it cannot be allowed otherwise, than that inflammatory metastasis to internal organs, par- ticularly the mucous and serous membranes, oc- casionally occur ; the internal disease taking place either in consequence of the suppression or disappearance of the external affection ; or the latter ceasing to exist, owing to the commence- ment or progress of the former. But, although the internal disease may retain the constitutional peculiarities attendant on the primary affection, yet its distinctive characters can no longer exist when it attacks a differently organised structure, from that to which they are chiefly owing. It is in such circumstances, and when internal inflammations supervene in broken-down consti- tutions, or from interrupted excretion and a morbid condition of the circulating fluids, as in the course of fevers, and in the puerperal state, that J. P. Frank and many other writers contend for in- ternal erysipelas ; similarity of morbid action, local and constitutional, although affecting dif- ferent structures, being considered by them as sufficient to warrant the appellation. 19. The Division adopted by Willan and Bateman — viz. 1. Phlegmonous; 2. OCde- matous; 3. Gangrenous ; and 4. Erratic — is faulty, inasmuch as the termination in gangrene is peculiar to no one state, but may occur in either the first or second variety.—Dr. Good associates certain varieties of erysipelas, with chil- blain and intertrigo, under the generic term of erythema. — Biett, Cazknave, and Schedel treat only of the True and Phlegmonoid. — One of the best and simplest divisions is by MM. Ali- bert and Rayer, into (a) the Simple, (b) the Phlegmonous, and (c) the QZdematous ; but it is defective, as it excludes certain states or com- plications which should not be overlooked, when treating of this disease.—Mr. James adopts a nearly similar arrangement, substituting merely the term superficial, for that of simple, employed by Raver.* * Synopsis ofthe Arrangement of different States of Ery- sipelas adopted by the Author. Species I. — Simple Erysipelas ; E. Simplex. Var. A.— Benign or Superficial Erysipelas ; E. Simplex Benignum. Var. B.— Acute Erysipelas ; E. Simplex Acutum. Species II.— Complicated Erysipelas; E. Compli- cntum. Var. A.— With (Edema oi the Subcutaneous Cellular Tissue. Var B.— With Inflammation ofthe subjacent Parts. 69* i. Simple Erysipelas — E. Simplex — E. Exanthematicum (Rust). — Febris Erysipe- latosa (Sydenham, Hildenbrand). — E. Superficial (James). — E. Verum seu Le- gitimum (Naumann.) 20. Charact. — Spreading inflammation of the skin, with soft and slight tumefaction, redness, stinging heat, fever, and frequently with vesica- tion. 21. A. The mild, benign, or superficial form, is atteuded by little constitutional disturbance, or only by slight inflammatory fever, or disorder of the digestive organs; the surface of the skin is of a pale or rose red ; vesication very seldom, or sparingly, occurs; and occasionally, after spread- ing to, or affecting, adjoining parts ofthe surface, and disappearing from those in which it first commenced, it terminates in resolution in the course of a few days, especially after the disorder of the digestive and excreting organs, on which it is usually dependent, has been removed. 22. B. The acute states are attended by more severe local and constitutional symptoms (§2.). They are preceded by marked disorder of the secreting-and excreting functions, and are accom- panied by smart febrile action. The skin is gen- erally red, hot, diffusely tumefied, and covered with small vesicles, and, in various parts, with large bullae. These generally break soon after their appearance, or about the fifth or sixth day of the disease, the fluid drying into crusts of va- rying colour and thickness ; the surface under- neath either healing rapidly, or becoming exco- riated by the acrid serum effused beneath them. In this latter case, the duration of the disease is longer, and the subsidence of the symptoms more gradual, than in the former. 23. C. The termination, which is usually by resolution, is preceded by a mitigation of the symptoms, after having continued in full force for three, four, or five days; and is attended by ex- foliation of the cuticle and of the crusts; resolu- tion generally taking place more rapidly in this, than in any other, disease of the integuments. But sometimes the sudden disappearance of the inflammation is followed by its supervention in some other part of the external surface — Erratic Erysipelas; and more rarely by asthenic inflam- mation of some internal part — Metastatic Erysi- pelas. These occurrences are most frequent when the local affection suddenly subsides, although the constitutional disturbance continues, and effete or morbid matters are still retained. The evacuation of copious offensive stools, or of urine depositing a large sediment, antecedently to, or about the time of, the disappearance of the local affection, is a sure indication of a salutary crisis. ii. Co m plicate dErysipf.l \s-E.Complicatum. 24. Charact. — The inflammation of the in- teguments ofthe kindabove defined (§ 1. 15.), as- sociated with disease ofthe adjoining strictures, or with prominent disorder of internal organs. 25. This species is very varied, owing to cir cumstances already enumerated, but chiefly to the severity of the attack, to its situation, to the states of the internal functions and of the con- stitutional powers, and to the exciting causes. Indeed, these latter circumstances mainly deter- Var. C.__With Inflammatory Disease ofthe Throat, kc Var. D.__With Nervous or Cephulic Affection. Var. E.__With Gastric or Bilious Disorder. 80 822 ERYSIPELAS —Complicated. mine the character of the former. The morbid associations, or more complicated states and se- vere degrees, of erysipelas, are those in which adjoining tissues suffer, or internal organs are dis- ordered, at the same time that the pathognomonic phenomena — the inflammation of the integu- ments— continue manifest. For, although me- tastasis to internal viscera, or the inflammation of other parts than of the skin, occurring in cachec- tic habits, or in those who are subject to this dis- ease, may, with great propriety, be viewed as erysipelatous, as respects the nature of the atten- dant constitutional affection, yet neither of them can strictly be considered as such, as regards the part affected. The erysipelatous character, how- ever, of the affection, under both circumstances, should not be overlooked; as thereupon ought to depend, in a great measure, the choice of remedies. 26. A. With (Edema, or Effusion into the Subcutaneous Tissues — E. QSdematodes of au- thors.—a. This state of the disease may be con- secutive of the simple varieties, or it may accom- pany them from the commencement, when they attack the face, or the vicinity of the organs of generation; effusion, in these cases, always tak- ing place in the loose cellular tissue. It often, also, supervenes in the progress of anasarcous swellings. Its primary form occurs chiefly in old persons, and broken-down constitutions, consecu- tively of chronic visceral disease, and in the leu- cophlegmatic and dropsical diatheses; the affec- tion of the skin and subjacent cellular tissue being nearly coetaneous. The external surface is of a pale or yellowish red, inclining to brown; gener- ally smooth and glossy; and it is seldom tense. It is but slightly hot or painful; and sometimes neither the one nor the other. The swelling in- creases gradually, extends slowly, and pits slightly on pressure. Vesications are not common; and the vesicles, which are small, numerous, and flattened, usually appear from the third to the fifth day; they break in a day or two, and are replaced by thin crusts. In the more active states, a sero-puriform, or puriform, fluid infil- trates the cellular tissue, or is discharged from the vesicated surface. The genitals, the face and scalp, the thighs and legs, are chiefly the seat of this variety. Dropsical limbs, especially when the cuticle is cracked or abraded, or after scari- fications have been made in them, are often af- fected by it; and, in these circumstances, there is a marked disposition to gangrene. 27. 6. CEdematous erysipelas terminates — 1st, in resolution, with absorption of the effused fluid; 2d, in suppuration; and, 3d, in softening, slough- ing, and gangrenous destruction of the part.— Suppuration occasionally takes place; but is gen- erally of an irregular or diffusive kind, extending in the course of the vessels, and between ten- dons and muscles; is preceded by a boggy state of the swelling; and is often attended by disor- ganisation of portions of the cellular membrane. —Gangrene is indicated by severe pain; and a red and glossy state of the surface, passing into a livid or leaden hue. 2S. B. IVith Inflammation of the Subcutaneous Structures — Er. Phlegmonosum vel Phlegmo- nodes, Auct. var.; Diffuse Phlegmon, Dupuy- tren; Er. Spurium, Pseudo-Erysipelas, Rust. —This is a most important and often dangerous disease; especially when epidemic, or propa- gated by infection. It is very varied in form and seat; and presents every grade of activity, from the passive or cedematous state, just de- scribed, to the most acute grades that rapidly pass into gangrene (§31.). — When it occurs sporadically, its local character is that of " dif- fused phlegmon;" the attendant fever being of an inflammatory kind, and preceded by rigors. In this case, vascular action is more acute; the swelling is greater -and more circumscribed; the pain and burning more remarkable, and more pulsating; the redness deeper; the temperature higher; and the disposition to pass into suppu- ration greater, but to change its situation less, than in other circumstances. Where the symp- toms are very acute, the subjacent cellular and adipose tissue frequently are profoundly affected; the fasciae, the intermuscular substance, and even the fibrous structures, becoming inflamed. In such cases, disorganisation of the cellular and adipose tissues often rapidly supervenes; the part passes from a brawny and tumefied, to a flaccid and boggy, state; and the attendant fever changes to a low or adynamic form. When occurring epidemically, or from infection, the local and constitutional symptoms are more severe; vital power and resistance are diminish- ed; and the disease is often complicated with a very dangerous affection of the throat and ad- joining parts. This variety may be divided, as suggested by M. Rayer, into three grades. 29. a. In the first, after rigors, and in con- nection with the constitutional symptoms describ- ed above (§ 2.), tingling, heat, and redness, fol- lowed by hard tumefaction of the part, begin to appear. A stinging pain, tension, and burning heat are complained of in the seat of swelling; which is diffused, hard, and deep-seated. After pressing the surface with the finger, the redness returns more slowly than in the superficial and simple disease. The lymphatic glands often be- come inflamed or enlarged; and febrile action is fully developed. If, about the fifth or sixth day, the skin be less red and tense, or covered by fur- furaceous scales, and the swelling subsides, reso- lution has commenced. Qldema oi the cellular tissue, however, sometimes remains for two or three days. But if the pain, about this period, become pulsating, suppuration in one or more parts is inevitable. The abscesses thus formed generally give issue to well-digested pus, and heal in a few days. 30. 6. In the second grade of this variety, in- flammation is more extensive; and the redness, heat, pain, and fever are greater. If the disease be not arrested, abscesses form, very insidiously, from the sixth to the ninth day, or even earlier; or a sero-puriform fluid infiltrates the cellular tissue, extending between the muscles and under the integuments; and, upon free openings being made, disorganised portions of this tissue are discharged with the puriform or ichorous matter. Fistulous cavities frequently are formed, giving issue to a foetid and ichorous pus. — Sometimes the skin is thinned or detached, and falls within the margin ofthe ulceration (Rayer). In these cases, the stomach and bowels frequently become irritable; and the patient dies, either from the exhaustion occasioned by diarrhcea, or by the ex- tensive suppuration and disorganisation of the cel- lular tissue; or from the absorption ofthe morbid ERYSIPELAS—Complicated. 823 secretion of the part, and the consequent conta- ! infiltrated, and tumefied. Most commonly, the ruination of the circulating fluids; or from those ; inflammation commences, with or after rigors, in causes combined: severe nervous symptoms \ the fauces or pharynx ; is of a dusky hue ; ex- (§ 35.) being either superadded, or taking the I tends along the nasal surfaces, and affects the place of this disorder of the prima via. face, scalp, &c. A sero-albuminous exudation 31. c. The third grade presents a still more is either partially or rarely seen ; the croupy acute series of symptoms. In two or three ; symptoms, which sometimes supervene upon this days, the inflammation of both skin and sub- [ complication, being owing rather to the exten- jacent parts reaches its acme. The skin is tense, sion of the inflammation to the mucous surface smooth, and shining; and of a deep or dusky red, ofthe larynx and trachea, and the infiltration of which is hardly a moment dissipated by the pres- ; the subjacent and surrounding cellular substance, sure ofthe finger. The swelling is profound, very | than to the exudation of lymph. In a few cases painful, intolerant of pressure, and diffused. In ! of the complication — one of them in the prac- this grade, and sometimes also iu the preceding, | tice of my friend Mr. By am, at the time of writ- the inflammation extends to, and beneath, apo- ' ing this—the cellular tissue of the throat, and neurotic expansions; and, occasionally, even to ofthe whole neck, was so distended, that the in- the periosteum, especially when the head is af- teguments appeared girt around them with the fected. The pulse is sharp and frequent; the : utmost tension ; and, in this instance especially, tongue is loaded and furred; and the excretions the respiration and cough were as distinctly croup- are offensive. There are, also, great thirst, restless-i al as in idiopathic croup. I have seen, iu some ness, sleeplessness, increased fever towards night, cases of this kind, the constriction of the integu- and delirium. About the fifth or sixth day, the ments so great, that incisions of them — as first inflamed integuments assume a violet hue, lose recommended by Mr. Copland Hutchison their sensibility, are softened, and covered by —were required, to arrest fatal cerebral conges- phlyctenae filled with a reddish serum. Soon ; tion or immediate strangulation. The constitu- afterwards, ecchymoses and sloughs form; and, tional disturbance in this state of disease is most at the same time, an ichorous suppuration, with acute ; and, at the commencement, attended by destruction of the cellular tissue, is established in high action, with deficient power. As the dis- the subjacent parts—Gangrenous Erysipelas, ease proceeds, the pulse becomes more and more' In favourable circumstances, the sloughs are de- frequent, unequal, irregular, soft, or small ; tached, and the parts beneath assume a healthy deglutition difficult or impossible; respiration some- character; but more frequently the patient sinks, times suffocative, wheezing, or sonorous and from the absorption of morbid matter causing croupal, with strangulating cough; and the ex- contamination of the fluids, or inflammation of cretions are always foul, morbid, and offensive. veins; with affections of the brain, of the stom- Delirium, coma, or sinking, preceded by rest- ach, aud ofthe bowels, as in the more severe lessness and anxiety, or disorder of the alimentary forms of adynamic fever. canal, are also generally observed. 32. d. The first and second grades of this vari- 34. This complication may terminate, in the ety often occur in the scalp, face, and neck ; and most acute cases, in the course of three or four are frequently further complicated with cerebral days — 1st, in suffocation, from the extension of affection, especially delirium, coma, &c. ; or with the disease to the' larynx and trachea, or from the gastric and bilious disorder; and with inflammation inflammation, infiltration, and tumefaction of the of the fauces and throat. The third grade, as cellular tissue surrounding these parts ; — 2d, in well as the first and second, is met with chiefly sphacelation ; — 3d, from the severity of the in the extremities, particularly after contusions, superinduced cerebral affection, in connection, fractures, and punctured wounds, and is sel- sometimes, with congestion of the lungs ;—and, dom preceded or attended by rigors. When oc- 4th, the symptoms may abate under very de- curring epidemically, as from infection, the cided treatment; and, as in the less severe cases, constitutional disturbance is greater and more may pass on to resolution, or to the formation dangerous; the pulse weaker and more frequent; of purulent collections, either near the eyes, or the "inflammation of the skin generally less, and about the angle of the lower jaw, or side of the that of the cellular tissue more remarkable, and neck. The formation of matter is generally in- more nearly approaching, if not altogether iden- sidious; this fluid being diffused throughout the tical with, diffusive inflammation of that tissue cellular tissue, and frequently deep-seated. When (see this article), than in other circumstances. this is the case, the result is usually fatal; owing 33. C. With severe inflammatory Affection of to the partial absorption of the matter, and to the the Throat and Larynx.— This affection may ac- effects caused by it on important parts in the company any of the forms of erysipelas attacking vicinity. the face; but it is most frequent in the phlegmo- 35. D. With Nervous or Cephalic Affection— nous variety, particularly when it appears epidem- Erysipelas Nervosum, of authors.—This is a ically, or from infection. Of this, the papers of common complication, where the disease affects Dr. s'ievf.nson, Mr. Arnott, Dr. Gibson, and the face or scalp, particularly the cellular sub- Dr. M'Dowel, furnish interesting illustrations, stance surrounding the eyes (Piorry); occurring In some cases, the extension of the disease over generally between the third and sixth days ; the nostrils and lips, to the fauces and pharynx, and in the course of other varieties, attacking may be traced. In others, the affections of the persons of weak constitutions and susceptible throat and face are almost coetaneous; and, in the nervous systems, especially when about to pass more severe cases, the face, throat, and integu- into dangerous exhaustion, or gangrene, or pre- ments down to the chest, with the cellular sub- vailing epidemically. In the former circumstance, stance'underneath, and surrounding the pharynx, there is evidently superinduced inflammatory trachea and glands, are more or less inflamed, irritation, or excited vascular action, in the mem- 824 ERYSIPELAS —Lesions in Fatal Casks —Diagnosis. branes of the brain, analogous to the vascular excitement of the skin, often occasioning an in- creased exhalation of serum : hence the delirium, passing frequently into coma. In the latter circumstance, the cerebral disturbance is the result rather of depressed vital power, manifested especially in the cerebral functions, and of the morbid changes in the blood, than of inflamma- tory action. The pulse is frequent, but variable as to fulness and power. The tongue is at first loaded, red at the point and edges, and after- wards dry in the middle, and of a brown or dusky hue. The excretions are suppressed or impeded ; and, in the worst cases, particularly towards the close, are passed unconsciously. Tremors, subsultus of the tendons, floccitation, &c. are then also observed. A fatal termination occurs generally from the seventh to the four- teenth day, or later. A bilious diarrhcea, or copious faeculent and offensive stools ; a free dis- charge of urine depositing a copious sediment; and a general, warm, and copious perspiration ; are favourable occurrences. 36. E. With Gastric and Bilious Disorder.— The bilious nature of erysipelas was strenuously insisted on by Stoll, Dessault, and others. Antecedent disorder of the digestive and assi- milating organs is more or less evident in all the varieties, but especially in this ; which is of com- mon occurrence during summer and autumn, when the digestive mucous surface and biliary apparatus are most liable to be diseased. It is generally attended by manifest signs of accumu- lated sordes and morbid secretions in the prima via, and of an increased secretion of acrid bile, especially when the disease is epidemic at the seasons just mentioned. 37. F. Erysipelas may, moreover, be com- plicated with inflammatory actiou of the mucous surfaces, analogous to that of the skin, giving rise to a form of bronchitis or gastritis. Where it is connected with inflammatory sore throat, it sometimes extends along either the trachea, or the oesophagus, or even both, until the lungs, or the stomach and bowels, are affected ; and, oc- casionally, along the Eustachian tube, to the ear : it thus becoming complicated with one, or even more, of these affections. This connection, first distinctly pointed out by J. P. Fr\nk, has more recently been insisted upon by Broussais, El- liotson, and others. Frank alludes to instances in which erysipelatous inflammation extended from the pudenda, along the vagina, to the uterus, and even to the bladder. Erysipelas may be further complicated with inflammation ofthe lym- phatics, particularly when caused by breach of surface ; or with phlebitis, when consequent upon injury, or when it has proceeded to suppuration. 38. G. Erysipelas may occur in the course of continued and remittent fevers ; and it may appear during convalescence from any of the exanthemata?. In the first of these associations, it generally presents an adynamic character, with nervous or with malignant symptoms ; frequently attacks the face, tfiGoat, anil scalp ; or the parts pressed upon in bed, or irritated by the evacu- ations ; and is especially disposed to grangrene. When it supervenes upon remittents, it often assumes a bilious or gastric form ; and in these, as well as in exanthematous fevers, it may prove a salutary crisis, if the pulse do not rise in fre- quency ; and if the cerebral functions remain undisturbed. In crowded sick wards, and in lying-in hospitals, it often occurs in the progress of other diseases, with which it consequently becomes complicated. But it is a most danger- ous circumstance ; as it is, in those cases, caused by an infected or impure air, which, favoured by the depressed state of vital power, or by imper- fect excretion, has contaminated the circulating and secreted fluids. 39. IV. Lesions in Fatal Cases. — When the cellular tissue has not been severely affected, the injection of the integuments subsides consider- ably after death; and hence the redness of the ex- ternal surface, as well as that of the throat, has often nearly or altogether disappeared. In addi- tion to infiltration of the subcutaneous tissues with serum, or a sero-puriform matter, and occa- sional disorganisation or gangrene of these and of the integuments, various internal lesions are com- monly observed. The blood in the large vessels and cavities ofthe heart is frequently semifluid ; and the veins proceeding from the part chiefly affected, are often inflamed, or contain pus ; as first observed byM. Ribes, and confirmed by MM. Dance, Arnott, and by my own observations, especially when the disease has been complicated with diffuse suppuration of adjoining cellular parts. In cases that have been attended by cephalic affection, the membranes of the brain are sometimes injected, or inflamed, and the arachnoid opaque, with serum effused between them, and in the ventricles; but, as M. Piorry has shown, these lesions are often not observed in this complication. Where the throat has been affected, the fauces, pharynx, and (Esophagus are of a dark or dusky red, or of a livid or brown tint ; much softened, sometimes with small patches of dark lymph on their surfaces ; -and the subjacent tissues infiltrated with a bloody serum, or with a sero-puriform matter. These appear- ances occasionally extend to the larynx and trachea, the submucous tissues being cedema- tous, or infiltrated with similar fluids. — In cases that have been associated with bronchial or pul- monary disorder, the lungs are congested with a dark semifluid blood ; the bronchi are of a dark red or brown colour, are injected, and often con- tain a frothy and bloody fluid ; portions of the lungs being cedematous, and others partially hepatised.—The mucous surface of the stomach and intestines is generally injected, of a deep or dark colour, often softened, and, where the bowels had been much affected, abraded, or inflamed, especially in the c;icum and rectum. The liver and spleen are seldom found in a healthy state, particularly in persons advanced in age ; but they present no lesions peculiar to this complaint, excepting that those usually resulting from in- temperance are most frequently observed. 39. V. Diagnosis.—The antecedent consti- tutional disturbance, with excited vascular action and drowsiness ;—the dull or yellowish red, or rose-colour, ofthe integuments, terminating in an irregular but well-defined margin, and disappear- ing, momentarily, on pressure ; — the pricking, stinging, and burning heat and pain of the part, sometimes with irregular vesications ; —the slight, plane, and diffused tumefaction, or the greater swelling and diffused affection of the cellulat tissue in connection with the inflammation of the ERYSIPELAS — Prognosis — Causes. 825 skin; — its rapid extension, or delitescence, or change of situation;—its almost uniformly acute or subacute character, as respects both the local and constitutional symptoms; — its manifest asso- ciation with disorder of internal organs, particu- larly of the digestive, assimilative, and excreting viscera, and of the brain and membranes; and its dependence upon a change in the circulating fluids; — its indisposition, owing to the states of vascular action and of the fluids, to confine or limit itself; and the inability of forming coagu- lable lymph, owing to these causes;—its infec- tious character under circumstances favourable to the manifestation of this property, more especial- ly when the constitutional affection is of an ady- namic kind, or when attended by sore throat; — the readiness with which it is repelled, and thrown in upon vital or important viscera; — its rapid termination in, or transition to, resolution and desquamation, or suppuration, or gangrene; — and, finally, the insidious and diffused manner in which purulent matter forms in the cellular tissue, when suppuration takes place; —are suffi- cient to distinguish the disease from erythema on the one hand, and irom phlegmon on the other. 40. VI. Prognosis. — There are various cir- cumstances which should influence our opinion as to results, in this disease; and determine us to give a guarded prognosis on all occasions : — 1st, Its tendency to relapse or to recur, from slight or unappreciable causes, or from errors in diet, &c.; — 2d, Its disposition to become associated with severe or dangerous internal affections; to disap- pear suddenly, and to be succeeded by them, especially diseases of the brain and its mem- branes, of the' air-passages and lungs, of the digestive Canal and peritoneum, and of the veins; — 3d, The age, habits, and previous health of the patient; — 4th, The causes which produce it, and the character of the prevailing epidemic; — 5th, The parts which it attacks, its particular form and complication, and the state of consti- tutional disorder accompanying it. 41. a. Recollecting that erysipelas is the ex- ternal expression of an internal or constitutional disease, we should consider the free manifesta- tion of it on the external surface, with little or no affection of the subjacent or internal parts, and without any remarkable depression of vital power, as a favourable circumstance, and not to be im- peded by external means. As long as it remains thus simple and superficial, and of neither a deep, fiery, nor purple colour, although it may be ex- tensive, and attended by vesication, it is not dan- gerous; unless it affect the face and head, and be accompanied with cerebral disorder. If it follow the stings of insects, the application of acrid sub- stances to the skin, or external injuries, it is sel- dom attended by danger, unless in cachectic or aged persons, or those addicted to the use of spi- rituous liquors. Stationary superficial erysipelas is less to be dreaded than the erratic; for, in the latter, there is greater risk of internal metastasis; and the erratic character is often connected with serious changes iu the nervous and vascular func- tions, or with latent internal disorder. 42. b. The risk of an unfavourable issue is generally great in proportion to the severity of the constitutional affection, — to the adynamic or nervous character of the attendant fever, — to the depravation of the circulating and excreted fluids, — to the deepness and darkness of the colour of the affected part, — to the severity of the cephalic disturbance, — to the extent and diffusive form of the inflammation and suppur- ation in the subcutaneous tissues,—and to the vital importance of the parts prominently asso-. ciated in the malady. Great tumefaction of the throat, scalp, or face, with prominence of the eye-balls; attendant disease of the fauces and pharynx, or of the respiratory passages and lungs, or of the stomach, intestines, &c; tenderness at the epigastrium, or over the abdomen; the dis- appearance of the external inflammation, and supervention of either of these, or of some other malady; and coma, jactitation, unconscious eva- cuations, &c.; are dangerous occurrences. The frequent or habitual recurrence of erysipelas, par- ticularly in persons advanced in life, indicates organic change in the liver; and its appearance about the organs of generation, in them, and in children, and around the umbilicus of infants, or in cedematous and dropsical limbs, especially after scarifications, is very unfavourable. A sim- ilar inference may be drawn when it attacks the face and scalp, particularly of delicate, aged, or broken down subjects; or follows severe injuries or surgical operations; or appears during conva- lescence from dangerous maladies, and when it is not preceded nor attended by shivering. Epidem- ic erysipelas, particularly in the crowded wards of hospitals, and during cold and humid states of the air, is attended by greater risk than sporadic cases. 43. VII. Causes.—A. There frequently exists a peculiar predisposition, or an erysipelatous dia- thesis, the nature of which has not been fully ascertained. It seems, however, to be connected with great irritability or tenderness of the cutane- ous surface, and defective power of the capillary vessels and secreting surfaces and viscera. Fe- males are much more predisposed than males, par- ticularly at the period of menstruation, and after the epoch of its termination. The irritable, bilious, and phlogistic temperaments; feeble, leucophleg- matic, and plethoric habits; the gouty diathesis; the autumnal, winter, and spring seasons; torpor or interruption ofthe biliary functions; an habitu- ally acrid and foetid perspiration; unwholesome and low diet; addiction to spirituous liquors; pre- existing visceral disease, general cachexia, and exhaustion of vital or constitutional power; are the chief predisposing causes. J. Frank sup- poses that young persons and females are most subject to erysipelas of the face and head; and the aged, to that of the extremities. Certain parts are more predisposed than others ; as the face, sexual organs, and lower limbs; owing to the greater sensibility and vascularity of the for- mer, and the liability of the latter to injury and external irritation. 44. B. The exciting causes are — a. Those which act locally, as injuries of the head and face; contusions, wounds, and fractures; surgical operations, particularly when performed ou ca- chectic habits; the scarification or puncture of anasarcous limbs; venisection, and the bites of leeches; punctures ofthe skin, and the inoculation of morbid, putrid, acrid, or septic matters; the stings and bites of insects; abrasions of the cuti- cle ; irritation caused by coarse articles of clothing, or by morbid secretions or excretions ; the appli- 826 ERYSIPELAS—Causes. cation of stimulating or acrid substances to the surface, particularly rancid oils and unguents; and the want of personal cleanliness.—6. The more general and internal causes are—exposure to cold and moisture; atmospheric vicissitudes; suppres- sion of the cutaneous excretion; a fish diet, and especially the use of shell-fish, or of dried, stale, or rancid fish; or of rich, oily, fat, or smoked meats; the suppression of accustomed secretions, excretions, and discharges — as the menses, hae- morrhoids, &c; violent mental perturbation; an impure state of the air, particularly a stagnant and moist air, loaded with animal effluvia; the miasm from persons affected by the disease, when confined in a close atmosphere; and certain con- stitutions of the air, which are recognised only by their effects. 45. In persons strongly predisposed, and par- ticularly in those who have experienced an at- tack, very slight errors in diet, and indigestible meats, especially such as are apt to induce a rancid, acrid, or acid change in the chyme; or spirituous or malt liquors in excess; very fre- quently induce a relapse or return of the disease. Indeed, whatever has the effect of altering the chyme and chyle from their healthy states, or of interrupting the functions of depurating organs, and thereby of changing the circulating fluids, either by the introduction of morbid and contaminating matters, or by the diminished elimination of hurt- ful or irritating elements, will excite this malady. 46. The influence of infection in causing ery- sipelas was first pointed out, and, indeed, proved, by Dr. Wells, the most original observer of disease in this country at the termination of the last and the commencement of the present cen- tury, when the state of medical science was by no means flourishing; and is fully confirmed by the observations of Pitcairn, Parr, Baillie, Dickson, Weatherhead, Stevenson, Ar- nott, Gibson, Bury, and Lawrence, referr- ed to in the Bibliography; and by evidence that has occurred to myself on more than one occasion. —When thus caused, erysipelas is very prone to attack the face and throat, and assume dangerous or even malignant characters; more especially if it also be epidemic. 47. C. Epidemic Erysipelas.—Most writers on the disease, from Hippocrates to the present time, have mentioned its occasional appearance in an epidemic form, and the circumstance of its characters partaking of the prevailing epidemic constitution. On most of the occasions of my seeing it, from 1814 to 1824 or 1825, it possessed more or less of a sthenic or phlogistic type; and depletions early in the attack, were then better borne than more recently; it having, for the last few years (till 1834), presented chiefly adynamic forms. Its appearance in hospitals as a circum- scribed epidemic is very common; and is gene- rally owing to impure air, particularly during the cold, raw, aud foggy east winds that prevail about the months of November and March ; when the external air is in some measure ex- cluded, and the air of the wards becomes loaded with miasms, or with the effluvium of one or more persons affected by it. In these circum- stances, the constitutional disturbance presents, or passes speedily into, the adynamic or nervous states; the secretions, excretions, and circulating fluids being more or less morbid. Thus, accord- ing to the particular epidemic constitution, the habit of body, the age and strength, and the modes of living, of those affected; the season in which it prevails; the contingent generation of an infectious effluvium, or of an impure and confined air; and the pre-existing state of the assimilating and excreting functions; epidemic erysipelas will appear with a predominance either of inflam- matory, or bilious, or adynamic, or nervous symptoms—on some occasions, with an inflam- matory appearance of the blood; on others, with a loose, dissolved, and otherwise morbid state of this fluid; and always with the excreting functions more or less disordered. In some instances, the integuments are chiefly affected; in others, and those the most dangerous, the subjacent parts are principally, and often insidiously, diseased. It occasionally does not confine itself to the situation it first attacked; and frequently it seizes on the face, neck, and scalp; and is sometimes compli- cated with a similar form of inflammation of the fauces, pharynx, and surrounding parts, or of the digestive or respiratory mucous surface. An abrasion, or some palpable irritation, of the cuti- cle, or external injury, is sometimes required to originate an attack ; but much more frequently it is the external expression of a morbid state of the frame, especially of the assimilating and ex- creting functions, and of the circulating fluids. On all occasions of its epidemic prevalence, the constitutional disturbance, ushered in either by rigors, or by irregular chills, precedes the local affection: sometimes in a very evident manner; at others, more slightly or obscurely; and, gene- rally, the formation of matter, and effusion of fluid into the cellular tissue, are not attended by the well-marked symptoms usually indicating them in more healthy states of the body.* * Hippocrates (Epid. 1. iii.) states, that erysipelas, epi- demic in the spring, sometimes continues through the sum- mer and autumn. — Bartholin and Sylvius describe an epidemic which was frequently complicated «ith inflamma- tion of the stomach and bowels. — Tozzi (Comment, in HlPPOC. Aphorism. 1. vii. §20.) remarks, that a fatal form of the disease was prevalent, during the autumn and winter of 1700, in Naples; and affected chiefly the face; deliri- um, epislaxis, and malignant symptoms rapidly supervening. When erysipelas is epidemic about the autumnal equinox, it sometimes abates during the winter, as remarked by Sydenham, and becomes again more prevalent in the spring. Richter at tes, that such was the case in respect of the epidemic of 1720-21, in I win. It attacked any part of the body ; but most frequently the face, neck,; and limbs. Epislaxis and a lax slate of the Dowels were favourable oc- currence*. Bloodletting, in the more phlogistic cases, and medicines to aid the depuralive processes, were found most beneficial.—In the epidemic of 1750, described by DaRLUC, the disease commenced with circumscribed redness in some part of the face, which spread over the head and face, and was attended by great tumefaction, a hard and frequent pulse, great thirst, anxiety, kc. In many cases, the affec- tion extended over the throat, was accompanied with ' diffi- culty of deglutition, hoarseness, a feeling of suff cation, and swelling of the external par s of the throat Bnd neck," with delirium, thick and turbid urine, subsultus tendinum, Sic.; and occasionally terminate I in sphacelation. Offensive f the Complicated Forms. 831 the disease, the attendant fever assuming this form, gentle tonics and diaphoretics are serviceable, especially the infusion of valerian, with the solu- tion of the acetate, and the aromatic spirit, of ammonia ; or the infusion of bark or of cascarilla, with the alkaline subcarbonates, and the pre- parations of camphor; or either of these infusions, with the tincture of serpentaria and the chlorate of potash. Richter remarks, that, when the attendant fever is of the nervous kind, the local affection is most prone to change its place, or to recede from the surface, and attack internal organs. I believe that there is much truth in this; and that these changes are less likely to occur when the above remedies are resorted to, and a blister is applied over the affected part; the excreting functions being moderately pro- moted by stomachic purgatives and enemata. 66. 6. Where delirium supervenes, its treatment must depend upon its form, the seat of the local affection, and state of the system. When the fever is ofthe nervous kind, delirium is an early symptom, and the result chiefly of the febrile action, and depression of nervous power; the means now mentioned, especially if morbid ex- cretions have been evacuated, being then bene- ficial. If the tongue be, at the time, moist, camphor and anodynes may also be prescribed. But when delirium is connected with general vascular excitement, depressed power, and mani- fest disorder ofthe circulating and secreted fluids, the alterative and stomachic purgatives, and ene- mata prescribed above (§ 55. 58.), are most to be depended on. Where the disease attacks the face and head, the delirium frequently proceeds from inflammatory action in the membranes of the brain, and rapidly passes into coma, from effusion and exhaustion of vital power. In this case, early bleeding from the feet, or cupping on the nape ofthe neck, or a number of leeches to the occiput and behind the ears; mustard pedi- luvia; cold applications to the head, if the heat be excessive and the patient young or robust; and active cathartics, both by the mouth and in enemata, are to be prescribed. If great and deep- seated tumefaction take place in the scalp, par- ticularly about the occiput, incisions should not be overlooked. 67. c. When profound coma comes on, the excretions being voided involuntarily and uncon- sciously, when the pulse is rapid, and the tongue and gums covered by a thick fuliginous coating, what measures should be resorted to? This oc- currence is frequent; is attended by the utmost danger; and is seldom satisfactorily treated. In several cases, I have resorted to the following means with success: — 1st, Unless calomel has been already taken largely, a full dose of it, with camphor, ought to be prescribed, in some thick substance, and placed upon the back part of the tongue, when it will gradually be swallowed ;— 2d, Two or three hours afterwards, turpentine, with an equal quantity, or with one half or two thirds the quantity, of castor oil, with a little liquor potassae, should be exhibited in the form of an electuary, and as just directed, if thecoma be profound, or in any other form, if the patient can be roused sufficiently to take it; and repeated frequently until the bowels begin to act; when its operation may be promoted by enemata (F- 150, 151.); — 3d, If matter form in any part, incisions 832 ERYSIPELAS — Treatment of the Complicated Forms. should be made early, and through the aponeu- rotic expansions, where there is the least risk of mutter forming beneath them* ; and 4th, blisters to the insides of the thigh, or to the nape of the neck, and between the shoulders, should also be directed, if the symptoms be not soon ameliorated by the preceding means; and the calomel and camphor repeated every five or six hours, until the tongue and gums evince the specific operation of the former; when warm or stomachic purga- tives, aided by the enemata already advised, and gentle tonics, ought to be given from time to time, to evacuate morbid secretions and support the vital powers. * The follnwing case occurred, eleven years since, to a very ble practitioner Mr. H. Cox, formerly House-Surgeon to the Infirmary for Children; and was soon afterwards pub- lished by him. I quote it in an abridged form, as it illus- tiates this complication, and the treatment recommended. It. 11101 cover is evidence of facts connected with the treat- ment not onlv of this but of other maladies :—"Jane Guest, aged 21, was seized, Jan. 22, 1824, with rigors, and fits of hystci ia to which she was subject. On the fourth dav, her scalp tnd become red and swollen, and the tongue tumid and red. Delirium and great restlessness afterwards supervened, and the erysipelas extended over the face and neck to the sternum. The eyes were now completely shut, and the features so swollen that she could not be recognised. In two or thre days she passed into a state of coma and insensibili- ty."—"The pulse, which was formerly full but easily com- pressed was now excessively quick; the tongue was black and crusted ; and she rolled towards the foot of the bed. The treatment usually resorted to in similar cases had failed to ameliorate any of the symptoms. The condition of the patient was. on the 31st of January, the worst possible. The pulse could not be counted ; she was profoundly coma- tose; the integuments of the head were distended to the utmost'. and the tongue, teeth, and gums were covered by a fuliginous coating. At thi. date, I stated the case to Dr. Copland, as one for which there was no room for hope. He strongly advised me to ixhibit the oil of turpentine in large doses, as he had experienced success from the use of it iii several cases characterised by similar symptoms to this." — "I had had many opportunities of witnessing the benefi- cial effects of this "substance at the Royal Dispensary for Childien, where Dr. Copland had introduced its frequent use. I, therefore, according to his advice, prescribed as follows : — " It Olei Terebinthina; § ss.: Olei Ricini " ij., Mellis 5 ij. Misce. Fiat Electuarium statim capiendum. "It Olei Terebinthina? 3vj.; Olei Olivae ^ j.; Aqua g x. Misce. Fiat Enema statim administrandum. "Feb. 1st.— Several offensive evacuations. Pulse some- what stronger, and not quite so quick. The coma is less profound. " K Olei Terebinth., 01. Ricini, aa J jss.; Mellis q. s. ut fiat Elect. Sumal, tertiis horis. partem quartam. " 2d.— The patient could be roused. The mouth, tt eth, and gums were cleaner ; the pulse 130, and fuller. The local symptoms were ameliorated. The oils have procured several bilious evacuations. " H Olei Terebinth. 3 jss. : 01. Ricini 5 ss- > Li1- P°" tassae 3 j.; Aq. Cinnamom. 5 iv- M. Capiat partem quar- tam quai tis horis. "3d.— Much better. Pulse 120, and more natural as to strength. The tongue is beginning to become clean. I he bowels have acted copiously, and much yellow bile has been voided. The patient now answers the questions put to her," &c. From this time her recovery was uninterrupted. (Lond. Med. Repos. for April, 1825, p. 299.) There is much misapprehension as to the operation of full doses of turpentine, given either by the mouth or in enema- ta ; many supposing {hat they increase vascular action in the brain. The reader will perceive, upon perusing the account (published in Ihe Lond. Med. and Phys. Journ. for May and July 1821.) of the experiments I performed — 1st upon myself; 2dly, upon the lower animals ; and, 3d ly, in numer- ous cases of disease — that this substance, given so as to act upon the bowels, either from the largeness of the dose, or by the aid of a purgative conjoined with it, is a powerful deriv ative from the brain, diminishes vascular action in serous membranes, and restores lost tone to the extreme capillaries, especially in exhalin: surfaces. The extensive experience I nave since had of this medicine has confirmed the^c infer- ences, but has shown that it maybe injurious in the hands of those who are not well acquainted with the exact circum- stances in which it may be given with advantage. 68. D. Treatment of Gastric and Bilious Ery- sipelas.—a. Where the yellowish coating of the tongue, the appearance of the surface, or of the excretions, and nausea or vomiting unattended by much tenderness at the epigastrium, indicate biliary disorder, an emetic, given early in the dis- ease, if the head be not seriously affected, is usually of service. After its operation, a full dose of calomel, purgatives, laxative enemata, diaphoretics, and the other measures already re- commended, according to the external character of the disease, and the states of general and local vascular action and of vital power, should be prescribed, and repeated as circumstances may require. Wherever tenderness of the epigastrium or hypochondria exists in connection with (he nausea or vomiting, local depletions in the vi- cinity, blisters, sinapisms, or warm terebin- thinated tpithems, placed over these regions, will be of essential service. The last of these should be applied until it produce redness, and be repeated according- to its effects upon the disease. Whenever any part within the abdominal or thoracic cavity is affected, either coetaneously with, or consecutively upon, or even after the disappearance of, erysipelas, these are the most effectual remedies, especially when aided by mercurials, prescribed either alone, or with camphor and opium. 69. b. Where this specific form of inflammation seems to affect the digestive mucous surface, small and repeated doses of nitre, with the subcarbonate of soda, in the decoction of quince seed, or ofthe lime bark; camphorated emulsions; diaphoretics in mucilaginous vehicles; local depletion, and the external means just specified, are most to be depended upon. In both this and the hepatic complication, calomel, blue pill, or hydrargyrum cum creta, may also be given with opium and small doses of camphor, until the gums are affected; but it also will often be necessary to evacuate morbid matters by stomachic and mild purgatives, and to support the strength by light tonics, especially at an advanced stage. In most cases of internal erysipelas, particularly if parts within the abdominal cavity be affected, calomel with camphor and opium, terebinthinated purga- tives and the epithems above mentioned (§ 68.), are of the greatest benefit. 70. E. The association with Inflammation ofthe Throat and Pharynx, being often attended by much danger, especially if the fever be of an adynamic kind, or if the head and face be affected, requires early and active treatment. Venaesection, or local depletion, or both, are frequently necessary; but the propriety of having recourse to them, and the extent to which either of them may be carried, must depend upon the state of general, as well as of local, vascular action, and vital power. Where there are great swelling of the external throat, and tension of the integuments (§ 33.), incisions should be made in the manner about to be directed (§ 80.), and the interna] treatment conducted appropriately to the states of the different functions, conformably with the principles developed above. If the swelling and tension be less, and the symptoms not so urgent as to require incisions, a large blister may be applied to the lower half of the neck, ex- tending over a part of the sternal region. Active cathartics, aided by the frequent exhibition o ERYSIPELAS —Local Treatment. 833 enemata (F. 135. 151.); gargles with a solution of the chlorate of soda or of lime; or of the nitrate of silver; and diaphoretics; are also very generally appropriate and beneficial. Although depletions are very often necessary in this complication, yet venaesection is sometimes injurious, and always in the adynamic forms, or at an advanced stage. In two cases in which I was lately consulted, an aggravation of both the local and constitutional symptoms followed bloodletting, though resorted to early, and in moderation. In this, as in every other form of the disease, the treatment should mainly depend upon the states just mentioned; and upon the various circumstances peculiar to the case. 71. F. Where the Erysipelatous Inflammation extends to the Larynx or Bronchi, or affects the Lungs, venaesection is frequently required, but not always to a great amount: in some instances, it has even appeared injurious. Local depletions, however, are generally necessary. The chief de- pendence should be placed upon the external ap- plications mentioned above (§ 68.), which ought to be repeated, sometimes oftener than once; and on purgatives, demulcents, and antimonials, or other diaphoretics; these being the chief means of exciting the excreting functions, and thereby of removing the constitutional derangement upon which the local affection depends. 72. G. When erysipelas supervenes in the course of fevers, venaesection is inadmissible; but the early application of leeches to the part is often of service. Internal inflammations appearing in connection with external erysipelas, admit not of vascular depletions nearly to the extent required by true or idiopathic inflammation; local deple- tions, calomel, camphor and opium, terebin- thinated purgatives and enemata, and the external aud other means just particularised, being the most efficient remedies in such cases. Whenever erysipelas attacks internal parts, it may be referred either to insufficient power to determine the morbid action to the surface, or to pre-existing disorder of the part affected, or rather to both. But as all such complications present similar states of vital action to the more simple forms of the disease — varying from the more phlogistic to the most diffusive or adynamic, ac- cording to the age, constitution, and habits ofthe patient, the causes and stage of the disease, and the characters of the prevailing epidemic—so do they require a treatment varying from the strictly antiphlogistic, to the most energetically restorative and tonic. 73. H. If Inflammation of the Lymphatics or of the Veins appear in the course of the complaint, or be associated with it — circumstances by no means uncommon when the upper or lower limbs, especially the former, are affected — general blood-letting is always injurious, and even local depletion is seldom beneficial. The liberal exhi- bition of tonics and stimulants; of stomachic and mild aperients; and of warm diaphoretics; with anodynes (§ 62.) if the pain and irritability be great; and emollient and anodyne applications to the part, particularly if the absorbents be in- flamed; are chiefly to be trusted to; the intention being, in all such cases, to arrest the extension of disease, and prevent the contamination of the cir- culating fluids. 74. The spurious forms of Erysipelas, which 70* are often connected with inflammation of deep- seated parts, and which most frequently occur in the extremities, should be treated according to the principles developed above, and in the article on the Cfllular Tissue; free incisions being particularly requisite for them (§ 80.). 75. /. Depletions and other antiphlogistic rem- edies are serviceable chiefly in a very early stage, whether of the simple or of the complicated dis- ease, however high vascular action may seom; and, although they have been most requisite at that period, and energetically employed, a very active recourse to stimulants and tonics will often subsequently be necessary. Frequently, also, where the propriety of resorting to moderate or local depletions is unquestionable, the good effects of restoratives and tonics, exhibited even at the same time, are equally manifest; this com- plaint, oftener perhaps than any other, requiring vital power to be restored by the latter means, whilst vascular action and congestion are being subdued by the former, and by medicines which promote the secreting and excreting functions. The stimulants most to be depended upon, are— camphor and ammonia, or their preparations, given iu large doses when the head is unaffected, or nervous power is exhausted; and the tonics al- ready mentioned. Various substances, which are both stimulant and tonic, as serpentaria, arnica, &c. are useful adjuncts to the barks; and others, which possess more of an antiseptic property, as the chlorates of potash or of soda, or the kreosote, are often of essential service, especially iu ad- vanced stages of the disease. The frequent and manifest dependence of the complaint upon a morbid state of the circulating fluids, has induced some writers to recommend the carbonates of the fixed alkalies, and such other substances as affect more immediately the state of the blood ; but although these are often beneficial, they ought not to be depended upon alone. The morbid condition of the blood is the result of imperfect action of the excreting organs, consequent upon defective vital power. The chief intention, there- fore, should be to excite the functions of these organs, by agents which operate specifically and beneficially upon them, and by those which rouse the vital energies generally, and resist the exten- sion of morbid changes. 76. iii. Of the local Treatment. — A. a. Cold applications have been recommended by several writers, but they are not always safe, and ought not to be prescribed when there is very evident adynamia, or for aged persons, or broken-down constitutions. In the more phlogistic states, at an early stage, and especially when these states occur in the face or head, they frequently afford much relief. — b. Warm poultices and fomenta- tions are objectionable in the phlegmonoid, and, indeed, in the other varieties, unless under some circumstances of the disease connected with local injury.—c. In the strictly constitutional complaint, neither of these are of much service ; dusting the part with flour or any other absorbent pow- der, when the vesicles break, or sponging it with some tepid and soothing fluid, if the heat and pricking pain be troublesome, being the safest practice. 77. B. a. The application of the nitrate of silver, in substance or in strong solution, as recommended by Mr. Higginbottom, is often of great benefit. 834 ERYSIPELAS —Local Treatment. It should be applied either to the inflamed surface and the adjoining integuments, or only to the healthy skin surrounding the affected part; and it should raise the cuticle, otherwise it will be of little benefit, and fail of isolating the disease.—b. 31. Larrey has advised the actual cautery to be applied lightly to different points on the inflamed surface, to the number of forty or fifty, with the view of concentrating the morbid action to the parts, and arresting its extension. — c. Blisters were employed first by M. Dupuytren with this intention. They are of great service in stopping the progress of superficial spreading and erratic erysipelas. But, even in such, when the complaint is very acute, bloodletting should pre- cede, as Dr. M'Dowel justly states, their appli- cation. They are seldom of use in the phlegmo- noid form, and never when purulent depute are likely to be formed. This writer concludes that blistering succeeds best when the inflammation is pale, or in patches, with but little tumefaction or pain ; and when proper constitutional treatment precedes and accompanies it. The blister should completely encircle the disease, covering about two inches, from the margin, of the inflamed, and as much of the healthy, surface, or it will extend at the unguarded point. 78. e. Mr. Reid and Dr. M'Dowel have giv- en extensive trial to mercurial inunction in this complaint, in two of the Dublin hospitals. They concur in viewing it as a valuable remedy, espe- cially in conjunction with such internal treatment as the case may require, in both the constitutional and the traumatic forms, whether affecting the head or the extremities. Two, three, or four applications have generally sufficed, and saliva- tion has frequently come on. Where the oint- ment cannot be rubbed, it should be daubed, upon the part. The recommendation of M. Ricord, who originated the practice, to use only the re- cently prepared ointment, is very . deserving of attention. 79. D. Mr. James mentions in favourable terms the application of spirits, and other stimu- lating substances, to the part. Dr. Peart pre- scribed a lotion, consisting of a drachm each of the subcarbonate of ammonia and the superacetate of lead, in a pint of rose-water. 1 have directed epithems of spirits of turpentine with benefit; but morbid secretions should be evacuated, the excreting functions restored, and stimulating di- aphoretics and tonics administered internally, before these should be ventured on in the con- stitutional forms of the malady. They are inad- missible where suppuration appears inevitable, or when vital power is much depressed, and where a tendency to affection of, or metastasis to, internal parts is manifest. In such, the dif- fusive stimuli are most serviceable given inter- nally. 80. E. The introduction of incisions into the treatment of erysipelas and its allied affections is considered by all candid practitioners in this country, and by the more recent Continental writers, as one of the greatest improvements in medical and surgical practice, and as solely due to Mr. Copland Hutchison. It has been alleged, that the same means were previously recommended by some of the older of modern writers. I have looked into them, in order to ascertain the fact ; and have found that, by two or three, superficial scarifications merely have been directed for certain morbid states, but not for erysipelas; these scarifications being quite different from the incisions practised by this au- thor, and such as have been adopted from the earliest ages as a mode of local bloodletting, among the inhabitants of both northern and in- tertropical countries. Since the publication of Mr. Hutchison's plan, modifications of it have been devised by Dr. Dobson and Mr. Law- rence—a number of minute punctures by the former, and one or two incisions many inches in length by the latter. There is now, I believe, but little difference of opinion among practical men, as to which of the three modes should be adopted. The extensive experience of Drs. Crampton, Young, Macfarlane, and M'- Dowel, and others, have decided the question. The fast of these remarks that, in phlegmonoid eiysipelas, early and free incisions, as advised by Mr. Hutchison, are of the greatest importance in immediately relieving, and speedily arresting, the disease; and in preventing sloughing of the fibrous and other tissues, and purulent infiltration of the cellular substance: their depth and number being proportioned to the extent ofthe inflamma- tion. The fascia? should be divided if the disease extend beneath them. The bleeding from the incisions ought to be watched, as it is sometimes profuse ; and it may, if uncontrolled, or unac- companied by a sufficiently restorative treatment, especially in old drunkards and broken-down constitutions, be attended by dangerous results. In these circumstances, and if the disease has been neglected till diffusion of pus in the cellular tissue, or sloughing, has occurred, before incisions have been made, lint dipped in spirits of turpen- tine, or iu equal parts of it and Peruvian balsam, should be applied, and covered by warm poul- tices. This practice has been prescribed by me for several years; and was resorted to in a most dangerous case attended by Mr. Hutchison, myself, and another practitioner, in the summer of 1834. Applications with the solution of the chlorate of lime, or of soda, or of kreosote, will also be serviceable in cases where sloughing has preceded the incisions or where spreading ulceration attacks their edges, as sometimes oc- curs in irritable and broken-down constitutions. When phlegmonoid erysipelas attacks the loose cellular substance about the eyes, the rectum, and scrotum, early incisions are requisite. — Where the scalp is deeply affected, they should pass through the aponeurotic expansions and pe- ricranium, the bleeding attending them often ren- dering further depletion unnecessary. 81. In erysipelas supervening in the advanced stages of low or malignant fevers, incisions should be made with great caution, and not unless im- peratively required, as the bleeding attending them, although moderate, may induce sudden or even fatal collapse, notwithstanding the contem- poraneous administration of restoratives. I lately met with such an occurrence. When suppura- tion has advanced or extended far, compres- sion by bandages, as recommended by Galen, Aetius, Heister, and more circumstantially by Dr. Dew An, should follow the evacuation of the matter by incision, in order to procure the adhesion of the opposite surfaces of sinuous cavities. But the compression ought to be so ERYSIPELAS IN INFANTS—Treatment. 835 applied, as to give a free discharge to the secre- tion by the outlet made for it. 82. iv. Treatment of Erysipelas in Infants and Children. — A. a. In the early stage of the complaint, the bowels ought to be kept freely open; calomel, or hydrargyrum cum creta, either with magnesia or the subcarbonate of soda, being given at first: and, if the fever be high, James's powder should be added, cooling dia- phoretics exhibited, and leeches applied be- hind the ears, or over the sternum, especially if there be associated affection of the bronchi or lungs. The infant should be restricted to the mother's milk, and even that ought to be given in diminished quantity. It will often be neces- sary to administer a stomachic or mild purgative to the nurse, and to attend to her digestive or- gans, and her diet.—b. In the second stage of the disease, when suppuration has commenced, the various tonics and stimulants already men- tioned — especially bark, quinine, ammonia, and the chlorates — should be freely administered. I have for many years prescribed the chlorate of potash with much benefit in this, and the allied affections. The chloric acid, with decoction of bark, and camphor, is also of great benefit. 83. e. Blisters have been favourably noticed by De wees, Physick, and others; but they require much more caution in this class of patients than in adults. They ought to be applied only for a few hours, or with very fine tissue paper inter- posed between them and the skin, and be removed as soon as their action commences; when warm bread and water poultices will complete their effect. — d. Mercurial ointment is, however, a much more generally appropriate application, particularly in very young children. If vesica- tions cover the part, they should be broken pre- viously to the application (Dewees); and if incrustations have formed, or if suppuration have commenced, the ointment may be applied to the inflamed margin, and a portion of the sound skin. Dr. Dewees states, that Dr. Schott has found a solution of corrosive sublimate, in the proportion of a grain to the ounce of water, equally beneficial with the ointment. In other respects, the constitutional and local treatment of erysipelas in infants should be conducted according to the principles developed above. 84. B. The affection of the pudendum occurring in children two or three years of age, and which Mr. K. Wood considers distinct from erysipelas, is certainly a severe form of this complaint, in very delicate, ill-fed, or cachectic children, or in those labouring under mesenteric or hepatic dis- ease. It is not a rare affection in large or manufacturing towns. Mr. Dendy (On the Cu- taneous Diseases incidental to Childhood, 8vo. p. 199.), my respected colleague for many years, and myself, have met with several cases, in both sexes, at the Infirmary for Children. In these, the weak and rapid pulse, the pale cachectic countenance, and the appearance of the affected parts, determined me to evacuate morbid matters by stomachic and mild aperients; to support vital power, and thereby to prevent the extension of the disease, bv the decoction of bark, with the chlorate of potash, or the medicines already men- tioned; and to prescribe applications with the solution of the chlorate of lime or of soda, or with Peruvian balsam. 85. v. Regimen and Diet.—a. The removal of patients to a pure atmosphere is of very great ad- vantage in the treatment; and fresh air should be freely admitted into the apartment, all sources of impurity, admitting of removal, being taken away.—The diet should be antiphlogistic in the early stage ; and in the more adynamic states of the complaint, it should be light and nourishing, and some agreeable and appropriate stimulant given along with it, as old sherry, or spirits for those who have been addicted to them. Chicken broth, beef tea, arrow-root, with old wine or brandy, become necessary, where suppuration, or destruction of the subjacent tissues, has super- vened; but, in the early stages of the phleg- monoid, or where there is plethora, abstinence from food, and from drink, excepting as much of the latter as is indispensable, should be en- forced. Whatever is prone to become acid or acrid on the stomach, as rich broths and soups, and all oily and fat matters, ought to be avoided. 86. b. During convalescence, change of air; light tonics, with alteratives and mild aperients; warm bathing followed by frictions of the surface, or slightly alkaline baths; due attention to all the secretions and excretions, especially to the bi- liary secretion; a course of alkalies with small doses of blue pill and taraxacum, when chronic disease of the liver is suspected; regulated diet, with a small proportion of lean animal food once in the day; the utmost temperance, and daily exercise in the open air; are the measures which will most probably secure the patient from a return of the disease, to which he is rendered very liable by an attack. M. Tissot justly ad- vises those who have had the complaint, to avoid the use of cream, milk, rich and viscid food, baked and strong meats, aromatics, warm spices, and strong wines; to shun a sedentary life, and mental irritation; to live on light cooling vegetable diet, and to drink water with a little wine. Biblio:. AND Refer.—Hippocrates, Aphor. vi. 28.; et Coac. 103.—Galen, Meth. Med. cap. xiv.; et Comment, in Aphor. 20. lib. iv.—Aetius, Telrab. iv. serm. ii. c 59.— Oribasius, Synopsis, 1. vii. c. 31.—Paulus AEgineta I. iv. c. 21—Aicenna, Canon 1. iv. fen. 3. tr. 1 c. 4—Schenck, Ordo et Methodus Scrulandi et Curandi Febrim Erysipel. Jenae, 1666.—Sydenham, Opera Universa. cap. vi. p. 279. (Bleeding and fomentations.)—JPiseman,Chiiurgical Trea- tises, veil. i. (Directs cupping and fomentations.)—Heister, Institutiones Chirurgica;, | art i. 1. ii. ch. 2.—F. Hoffmann, Opera, vol. ii. sect. v. (Infantile.)—R. Brocklesbury (Eco- nomical and Medical Observations, from 1758 to 1763. Lond. 1764, p. 139. (Bloodletting and nitre.)—Grant, On Fevers, p. 391. (Emetics.)—Lorry, De Morb. Culan. 4to. p. 192.— Sauvages Nosol. Mtthod. vol. i. p. 449. (Specifics an in- fectious form )—Schroeder, De Febribus Ervsipelatosis. Goet. ffll.—W. Bromfield, Chirurg. Observ. 2'vol. Lond. 1773.; and Med. Communications, vol. ii. p. 322— olby, in Ibid. >ol. ii. No. 3.—Trommsdorf, Hist. Erysipelatis et Feb. Erysipel. Causa Materiali, kc Erf. 1780.—Latta, Svstem of Sur^-iry, vol. i. ch. 6. (Leeches to the part.)— Stoll, Rati.) Med. vo'. ii. p. 80. 172. (Emetics.)—Cullen, First Lines, kc § 1695.—Oehme, De Morbis Recens Nato- rum Chirurg. p. 40.—Ammon, De Erysip. ejusque Ab. Iu- flammatione Diversitale. Hard. 1790.— Gnrthshore, in Med. Communications, &c. vol. ii. art. 5. (Infantile.)—Vogel, in Loder, Journ. f. d. Chirurg. b. ii. p. 254. (Leeches to the part most inflamed.)—Feme, De Diversa Erysipelatis Na- tura, 4lo. 17&5.—Collingwood, Edin. Med. Comment, vol. xvi. p. 53.— (The decoctum ulmi.)—Walshman, Memoirs of the Med. Soc. of Lond. vol. v. p. 182. (In children, compli- cated with gastritis.)—Peart, Pract. Observat. on Erysipe- las, 8vo. Lond. 1802.—Desuult. (EuvresChirurg. par Bichut t. ii. p 581.__Underwood, On Dis. of Children, vol. i. p. 31. 5lh edit.__Hufeland, Die Rose neugehorner Kinder. Journ. b. x. st. 4. Ho. 8., et b. xxii. st. 2.—Sybel, in Ibid. Nov. 1811, p. 91. (Termination in induration of cellular tissue.) —Henke, in Horn's Archiv. b. vi. h. i.—Marcus, Magazin f. 836 ERYTHEMA— Primary. Specielle Therapie Klinik. b. ii. st. 2.—Schmalz, Versuch einer Medic. Diagnostik. Leip. 1806.—K. Sprengel, Handb. d. Palhol. th ii. 3 e Aufl. Leip. 18 fl.-J. Pear on. Prin- ciples of Surgery, kc p. 191.—J. V Hildenhrand, Ralio Medendi in Schola Practica Vindoboii. pars ii. 1809—13.; et Institutiones Piaclico-Medicae, kc t. iii. p. 590.—Horn, Archiv. Nov. 1810, p. 395. (Emetics, when commencing in the face.)—Velsen in Ibid. Nov. 1811, p. 426. (Infantile.) —Parr, Diet, of Medicine. Inverbo. (Infectious.)—Lassus, Pathologie Chirurg. Par. 1809 t. i. p. ».—J. P. Frank, De Curand. Horn. Morbis, I. iii. Ord. i. Gen. 1.—J. Thomson, Lectures on Inflammation, p. 512.—Richerand, Nosograph. Chirurgicale, t. i. p. 118.—Dewar, in Trans, of Med. and Chirurg. Soci tv, vol. vii. p. 477.—K. Wood, in Ibid. vol. vii. p. 82.—J. A. F. Ozanam, Hist. Medicale des Maladi s Epidemiques, t. v. p. 223. (Notices the complication with angina.)—J. Hennen, Principles of Military Surgery, 2d ed. Edin. 1820, p. 282.—G. Fordyce, Trans, of "Soc. for Improv. Med. and Chirurg. Knowledge, vol. i. p. 290. (The throat affected—chiefly bark for the cure.)—Wells, in Ibid. vol. ii. p. 213. (Infection:—treated by bark )—G. Blane, On the Diseases of Seamen, 3d edit. p. 600—Boyer, Traite des Malad. Chirurg. t. ii. p. 6.—A. C. Hutchison, Trans, of Med. and Chirurg. Soc. vol. v. p. 273. ; and Practical Ob lervat. in Surgery, 2d edit. Lond. 1826, p. 110.—J. Frank, Praxeos Medica Universal Piaece, ta, pars i. vol. ii. p. 116. —Patissier, Sur 1'ErysipeJe Phlegmoneux, 4t<> Paris, 1815. —P. Bretonneau, De 1'Utilite de la Compression, kc ; et Diet, des Sciences Med. t. xii.—A. P. W. Philip, A Trea- tise on Simple and Eruptive Fevers, 8vo. p. 267.—A. G. Richter, Specielle Therapie, b. i. Berl. 1817.—J. Beding- fitld, A Compendium of Med. Practice. Lond 1816, p 296. —Striim, in Acta Nova Reg. .Soc. Med. Havn. vol. i. 1818. (Of the malignant state of erysip.)—Weatherhead, Diagno- sis between Erysipelas, Phlegmon, kc 8vo. 1819.—Dickson, in Med.-Chirurg. Rev. April, 1819, p. 615.—Haden, Pr.ict. Observat. oi Colchicum, 8vo. 1821. (Colchicum in the phlegmonoid.) -Fodiri, Lecons sur les Epidemies, itc. t. iii. p. 341.—J. N. Rust, Das Pseudo-Erysipelas, in Rust, M gazin. h. viii. h. 3. p. 493.—F. W. Hemmer, D. Rise der Neugebornen, &c.—Harless, Rhein. Jahrb. b. viii. st. 3. p. 55 — Larrey, in Revue Med t. i. 1826, p. 177.—J. E. Un- gewitter, De Pseudo Erysipelate. Berl. 1824.—Bateman, Synep. of Cutaneous Diseases, edit, by Thomson, p. 175.— W. H. Burrell, Edin. Med. and Surg. Journ. vol. xxiv. p. 2J.7. (Leeches and warm fomentations.)—A. Carlisle, Lond. Med. Gaz. vol. i. p 400.— W. P. Dewees, On the Physical and Medical Treatment of Chi dren. Lond. 1826, p. 308.— W. Lawrence, Trans, of Med.-Chirurg. Soc. of Lond. vol. xiv. p. 3.—Dobson, in Ibid. p. 206.—.4. Cooper, Surgical Ltciures, vol. i. p. 249—Plumbe. On Dis. of the Skin, 2d ed. 1827.—Roux, Archives Gener. de Medecine, t. xiii. p. 189. (Emetics at the commencement.)—Guerin, in Ihid. t. xv. p. 27. (Compression by bandages.)—Schmidtmann, Sum ma Observat. Medicar. kc. vol. iii. p. 371.—C. Billard, Tr he des Maladies des Enfans. Paris, 1828, p 113.—Saba- tier, Sur l'Krysip. consjdere comme Moven curatif dans Affect. Cutan. Chron. 4to. Paris, 1831.; e't Bullet. Ge er. de Therapeutiqu , Juin, 1833.—Cazenave et Schedel,Abre%e Pi at. des Maladies de la Peau, 8vo. Par. 1828, p. 9.—J. Abernethy, Lectures on the Theory and Practice of Sureerv, Hvo. Lond. 1830, p. 67 —J. Stevenson Trans, of Med.-Ch'i- rurg. Soc. of Edin vol. ii. p. 127.—W. Gibson, in Ibid. vol. iii. p. 94.—Labauche, Nouv. Biblioth. Med. t. vi. p. 59.— Tr..vers, in Lond. Med. and Phvs. Journ. vol. lvi. p. 439.— Higgenbottom, in Ibid. vol. lviii. p. 223.—Storer, in Ibid. p. 227.— Earle, in Ihid. vol. lix. p. 22.—Cases, in Ibid. p. 17.—Lawrence, in Ibid. p. 225.—J. Arnott, in Ibid. vol. Ivii. p. 193.; and Lond. Me I. Gazette, vol. xiv. p. 218.—W. Young, Glasgow Med. Journ. vol. ii. p. 241.—J. H James, Observ. on the General Principles, and on the Nat. and Treatm. of Inflammations, 2d ed. p. 370.—Piorry, Gazette Medicale, No. 42. 1833. (On cerebral affections from.), et Clinique Med. kc 8vo. Paris, 1832, p. 390.—Ricord, Lan- cctte Francaise, 1832, passim, et No. 52. 1883. (Mercurial ointment fur.)—Dupuytren, Lancet, No. 543. p. 665. (On phlegmonoid erysip.) —Alibert, Med. and Surg. Journ. vol. v. p. 174.—Good, Sludy of Med., by 1 ooper vol. iii p. 72. 3d edit.—Rayer, in Diet, de Mid. et Chirurg. Prat. t. vii. p. 483. (Recommends incisions, and gives due credit to the originator of the practice.)—J. Bullock, Medical Quarterly Review, vol. ii. p. 183. (Colchicum with the alkaline sub- carbonates.)—Crampton, Med. and Surg. Journ. vol. v. p. 369.-5. Cooper, in Ibid. vol. ii. p. 773.—Bury. Med. Ga- rotte, vol. xii. p. 533.—Elliotson, in Ibid. vol. xi. p 182.— J. Bui-ns, Principles of Surgery, vol. i. p. 188.—Theden, Bulletin Gener. de Therapeuliquc, May, i834. (On com- pression in the treatment of phlegmonoid erysip.)—S. Cooper, Lectures on Surg ry, in Lond. Med. and •'-urg. Journ. vol. ii. p. 775.—Macfar/ane, Clinical Reports, &.c. Glasgow, 1833. ; and«/oAn«>n'j Med. ( hir. R v Julv 1"34. -E. MDowel. Dub.in Journ. of .Med. and Cheiu. Science, vol. vi. p. 161.—Berndt, Encyclop. Wortetbucli d. Medicin ischen Wissenschaften t. xi. p. 478.—J. Armstrong, Ltfi tures on the Nature and Treatment of Acute and Chronic Diseases, edited bv J. Rix. tvo. Lond. 1834. (The account of erysipelas is imperfect, confused, ami interlarded with cant!) ERYTHEMA. —Syn. '*W6V« (from fytu rW, red), Gr. Erysipelas, Celsus and Galen. Erysipelas idiopathicum, Sauvages. Dartre erythemoide, Alibert. Die Rathe, Hautrothe, Germ. Erytheme, Fr. Classif. — 1. Class, Febrile Diseases; 2. Order, Inflammations (Cullen). 3. Class, Diseases of the Sanguineous Function; 2. Order, Inflammations (Good). III. Class, I. Order (Author). 1. Dkfin.—Superficial redness, with burning pain, of a part of the integuments, varying in extent and form, disappearing momentarily on pressure, usually of an acute character, and \ uninfectious. } 2.1. Description.—The varieties of erythema and of erysipelas have been confounded together [ by many writers, — a circumstance almost un- avoidable, when it is considered, that several states of the one are merely modifications of certain forms ofthe other; distinctions between them be- ing rather conventional and artificial, than essen- tial, distinct, and unvarying. Hippocrates used the term erythema merely to signify simple red- ness of a part. Callisen, Sauvages, and Rostan employed it to designate the slightest grade of erysipelas. J. P. Frank and J. Frank applied it to several affections of a chronic kind, entirely distinct from those to which it has been given by recent British and French pathologists. Cullen viewed it as a superficial inflammation ofthe integuments, but little, or only symptoma- tically, affecting the constitution; aud erysipelas as an affection primarily, and chiefly of the whole system. Willan, Bate man, and Rayer con- sidered erythema as generally connected with more or less constitutional disorder,.—a circum- stance that cannot be disputed, although such disorder is frequently latent, or but little evident. Dr. M. Good has detached two of the most com- mon forms of complex erysipelas, viz. the phlegmonoid and edematous, from that head, and comprised them under this, — an arrange- ment in so far improper, as intimately allied and serious affections, depending upon very manifest febrile disturbance of the system, are thereby separated, and certain of them placed in con- nection with others unattended by any marked disorder, and of comparatively little importance. Erythema is either primary, and proceeding from local causes; or symptomatic of some other dis- ease, or of constitutional disorder. 3. i. Primary or Idiopathic Erythema presents various modifications, according to its causes and seat.—A. Er. Intertrigo, Salvages, Willan —E. ab Acri inquilino, Cullen— Ecorchure, Fr.—Fret, or Excoriation of the Skin—generally proceeds—(a) from the friction of two contiguous surfaces, particularly in fat per- sons, as in the upper parts of the thighs, arm-pits, &.c.;—(6)or from the irritation of morbid secretions coming or remaining in contact with parts, as ofthe perspiration in the groins,and below the mamma'; or of the leucorrheal discharge, or catamenia, and of the alvine and urinary excretions, particularly in the course of other diseases;—(c) or from chemical ERYTHEMA —Symptomatic —Chronic 837 or mechanical irritants, and artificially from si- napisms, or ammoniacal and terebinthinated lini- ments, &c; — (d) or from excessive heat, or vicissitudes of heat and cold, or the rapid abstrac- tion of heat — E. pernio, or chilblain;— (e) or from pressure, especially lying long in one posi- tion — E. paratrima, Sauvages ;—(/ ) or from the stings and bites of insects, etc. —E. punctura of Sauvages. 4. When the epidermis is partially removed in this species of erythema, either by friction of the suffices, or by the excoriation produced by acrid secretions, as in the intertrigo occurring in fe- males and infants of a full habit from neglect of due cleanliness, a serous or sero-puriform fluid exudes from the inflamed surface during some days; but vesicles are not formed, nor is there any manifest swelling ofthe part as in erysipelas. 5. ii. Symptomatic Erythema—VErytheme Symptomatique, Biett, Rayer, Cazenave, &c. — often accompanies other eruptions, espe- cially at their commencement and termination, as remarked by Billard; and is occasionally complicated with them. It most frequently is dependent upon disorder of the digestive organs; and is often observed in children about the pe- riods of dentition, in plethoric or fat persons, and at the critical periods of female life. It is most commonly caused by the ingestion of irritating substances, and by certain kinds of food, espe- cially in irritable temperaments, feeble or deli- cate constitutions, and individuals of a peculiar diathesis. 6. A. Fugacious Erythema—E.fugax, Wil- lan, Bateman—the macula volatica of various writers — consists of irregular and evanescent red patches, with increased heat of the part, which appear successively on the arms, neck, breast, and face, in various febrile diseases, and in bilious fevers and diarrhcea(BATEMAN); often denoting, as Hippocrates has remarked, a tedious and dangerous malady. This variety sometimes attends derangements of the digestive organs, and, more rarely, hysteria and hemicrania. [lis not usually followed by sensible desquamation ofthe cuticle; but exceptions to this occasionally are observed. 7. B. Shining Erythema—E. lave, Bateman — is sometimes symptomatic of disorder of the prima via, and occasionally attends the catamenia in delicate and irritable females; but it most fre- quently accompanies anasarca, or cedematous swellings. The inflamed surface is smooth and shining. Wrhen it affects young and sedentary persons, it is often attended by slight fever, and it generally terminates in extensive desquamation as the anasarca subsides; but where it occurs in aged persons, or in those addicted to intemper- ance, it is liable to pass into spreading or slough- ing ulcers. It is merely a modification of cede- matous erysipelas. 8. C. Marginated Erythema—E. marginatum — occurs in patches, bounded on one side by a slightly elevated, tortuous, red border; but the redness has no boundary on the open side. It appears on the extremities and loins of old persons, produces little or no irritation, and re- mains for an uncertain time. It is generally connected with internal disorder of a serious or dangerous tendency. 9. D. Papulated Erythema — E. papulatum, Bateman —appears chiefly on the arms, neck, and breast, in irregular extensive patches, and most frequently in females and young persons. The patches are of a bright red hue, often slightly elevated; and, for a day or two, before the colour becomes vivid, they are rough or imperfectly papulated. The redness afterwards continues for several days; and, as it declines, assumes, in the central parts, a bluish or pale purple tinge. This variety is generally attended by a tingling sensa- tion, passing to soreness as the colour changes; and sometimes with much constitutional disturb- ance, — with a frequent small pulse, anorexia, depression of strength and spirits, watchfulness, and pains or tenderness of the limbs; but the general disorder is often trifling. 10. E. Tuberculated Erythema — E. tubercu- latum — is merely a slight modification or an advanced stage of the papulated. The patches resemble those of this variety; but there are small, slightly elevated tumours interspersed through them, subsiding in about a week; the erythema becoming livid and disappearing in about a week more. It commences with fever, is attended by languor, irritability, and restless- ness; and is succeeded by hectic. It is so rare, that Bateman never met with it, and Willan saw only three cases; and, in these, treatment did not " alleviate the symptoms nor prevent the subsequent hectic" (Bateman). \\. F. Nodose Erythema — E. nodosum— af- fects chiefly females, children, and young persons of a lax and lymphatic constitution; and rarely occurs in boys. It is preceded by slight febrile symptoms, for a week or more, which generally abate upon its appearance. It shows itself on the fore part of the leg, and rarely on the arm, and, in large oval patches, the long diameter of which is usually parallel with the tibia, and slowly rises into hard and painful protuberances. In the course of nine or ten days these soften and subside, the red colour turning bluish or dusky a day or two earlier. It is sometimes connected with the approach of the catamenia; and its pre- mature disappearance is sometimes followed by dangerous internal disease. Mr. Dendy saw pneumonia suddenly supervene on its retroces- sion. 12. iii. J. Frank and Rayer have described, as a chronic form of erythema, the redness affect- ing parts of the face, and often associated with Acne, particularly A. rosacea, which it sometimes so nearly resembles, as to appear rather as a mo- dification than as a complication of that eruption.* It generally commences in the nose, extending to the cheeks, and more rarely to the forehead and chin; is characterised by vascular arborisations in the alee nasi and summits of the cheeks, with shining redness disappearing momentarily from pressure; and is attended by a sensation of heat, tension, and itching, which, with the redness, are increased by external and internal stimulants, or whatever determines the blood to the head; and, * NTcolai-s Nr. olus Florentinus took a tolerably accurate view of these complaints, in making them varieties; or degrees of the same eruption. The onelieie described he names, " Rubedo simplex seu fades rubra ;" the Acne rosacea, he calls '■ Rubedopustulosa" (Serm. vii. tr. vi. cap. 15.): and T. Mayerne was, upon the whole, right in con- nectine the former with disorder of the liver Opera Med- ico, p.~2l3.), and in prescribing for it, local depletions from the nape of ihe neck, and behind the ears, setons, mercurial purgatives, antimonials. kc $2 838 ERYTHEMA—Causes —Diagnosis—Treatment. at first, by slight exfoliations of the cuticle. The reddened skin, at much later periods, becomes irregularly granulated, rough, thickened, and occasionally tuberculated. It is dependent upon protracted disorder of the digestive organs, usu- ally resulting from a long course of indulgence or intemperance, and seldom appears till after middle age. 13. iv. M. Alibert describes two other spe- cies of erythema, — the Epidemic and Endemic. The former is characterised by burning itching, with pricking in the hands and feet. In some cases, the skin is red; in others, it is black, as if covered with a layer of soot. The epidermis ex- foliates, or forms vesications; and the constitu- tional symptoms are very severe. This disease was epidemic in Paris in 1828. The endemic is the chronic affection of the skin, which attacks the peasants of the north of Italy, and is better known by the name of Pellagra(u>/u'c-A see). 14. II. The Causes, particularly of primary erythema, have been already noticed (§ 3.); but, even when appearing in this manner, it is favoured, if not in a great measure caused, by disorder of the digestive and excreting organs. It often accompanies dentition and diarrhcea in children; and, in them especially, is frequently caused by particular kinds of food, or by errors in diet. It sometimes appears in the course of dysentery or fevers; and is indicative of inflam- mation or suppuration below fascia?, or in deep- seated parts; it then generally assuming the shining or smooth form. Vascular plethora; the critical epochs in females; various irritating in- gesta; very warm spices; disorder of the stomach, liver, and bowels, or of the excreting or elimi- nating functions; are chiefly concerned in its production. 15. III. Diagnosis.—A. The superficial red- ness; the absence of tumefaction and vesication; the more or less circumscribed patches; the much less constant, severe, and burning pain; the generally slight form, and favourable termination, of both the local affection and the constitutional disorder; sutficiently distinguish erythema from erysipelas.—B. The redness is deeper in shade and in situation, and the patches are larger, but less numerous, in erythema than in Roseola: the latter eruption often appearing simultaneously in different parts of the body, which is never ob- served in the former. These two affections are, however,often distinguished from one anotherwith difficulty; and there can be as little doubt, that they often insensibly pass into each other, as that they are both symptomatic of internal disorder; as, indeed, Mr. Plumbe has properly observed. 16. IV. Treatment. — A. The primary or idiopathic forms generally disappear readily upon the removal of the causes which occasion them; aided by frequent tepid ablution, and by some mild absorbent powder, as that of calamine or of cerussa. When erythema occurs in infants, from inattention to the removal of the urinary and intestinal excretions, the tepid semicupium, mild aperients, and saline diaphoretics, may also be employed; and if it be attended by a serous or foetid discharge, a lotion with a weak solution ofthe chlorate of lime or of soda, or of kreosote, will readily restore the parts to a healthy state. If the part be very irritable, Dr. Bateman directs a lotion consisting often grains of oxymuriate of mercury and six ounces of lime-water. A weak solution of the nitrate of silver is also of great service. — When it is produced by cold — E. pernio — turpentine and the balsams, or the former and tincture of camphor, soon remove it. — If it be caused by bites or stings of insects, ammonia and the essential oils are generally be- neficial. — Erythema from pressure may be re- moved by the use of air-pillows; by spirituous, camphorated, or terebinthinated applications; and by suitable means of protecting the surface. 17. B. The symptomatic states of erythema should be treated according to the indications of internal disorder furnished by individual cases; and almost entirely by internal or constitutional means. The principles advocated in erysipelas, viz. that the excretions should be promoted, and the digestive and assimilating functions assisted, ought also to be followed in these affections. Therefore, deobstruent and alterative purgatives; mild tonics, with the alkaline subcarbonates, and diuretics; diaphoretics with sedatives, particu- larly at bedtime, as James's powder with small doses of calomel and opium, or hyoscyamus, are the most generally appropriate. In the papulated variety (§ 9.), gentle laxatives, mild tonics, and light diet, are sufficient; but, when local irrita- tion, or restlessness, is much complained of, anti- monials and anodynes may also be given at night. —The nodose variety (§ 11.) is soon removed by rest; small doses of mercurials, with James's powder, at-bedtime; alterative mild purgatives given in the morning; and light tonics in the course of the day. Change of air and light diet are also of very great benefit. External applica- tions are seldom useful, and may be hurtful. If this or any of the other varieties be connected with suppression of the catamenia, or of other discharges, bloodletting should precede the means recommended above; and measures ought to be used to restore the evacuation. 18. C. The chronic form of erythema (§ 12.) should be treated in the manner advised in the article Acne (see § 23. et seq.), particularly for the indurated and rosaceous varieties, with which this form is often associated. Temperance; light mild diet; regular exercise; avoidance of stimulating and heating ingesta, especially hot spices, spirituous liquors, acescent vegetables, and fat meats; mild tonics and laxatives, with the alkaline subcarbonates; and frequent and very small doses of blue pill, or hydrargyrum cum creta, with taraxacum, &c; constitute the most appropriate remedies. Astringent or other repellent washes are of use only at the com- mencement of the eruption. When it has become more diffused or chronic, it is not much affected by these applications; and if it were, the propriety of suppressing it by such means would be very questionable. When first appearing, the washes mentioned in the article Acne, and a solution of borax in weak pyroligneous acid, are most useful. The severer forms of erythema, especially the shining, or cedematous, and the tuberculated, should be treated in the manner recommended for similar states of erysipelas; and the regimen and diet directed in that article ought to be adopted in this disorder. Bibliog. and Refer.—Celsus, De Medicina, I. t. cap, 28. § 4.— Cullisen, *ystema Chirurg. Hodiern § 483. __D. Turner, A Treati.e on Diseases of thi. Skin, 5lh EXANTHEMATOUS DISEASES —Pathologt. 839 ed. 1736, p. 239.—Cullen, First Lines, . Lond. 1772, p 362.—Sagar, "S. tema Morborum, &.c. Vien. 1776, p. 55'. class x.—Cullen, Synopsis, class i. order 3.—C. T. Selle, Liber de Curandis Hominum Morbis, cura C. Spren- gel, 8vo. 1798, p. 102.—J. P. Frank, De Curand. Horn. Morbis Epitome, 1. iii. vol. i. p. i.—B. Parr, The Lond. Med. uii-iiuiiwy. &c. tin. I ond. 1809, vol. ii. p. 269.— K. Sprengel, Institutiones Medica; vol. i.. Pathologia Speci alis. Amslel. 1814, 8vo. p. 390.—Author, in Lond. Med. Repos. vol xvi. 1822, p. 377.—Rayer, Malad. de la Peau, t. i. p. 12.—Cuzennve et S-hedel, Ahrege des Mai. de la Peau, p 1.—J. Paget, in Edin. Med. and Surg. Journ. vol. xl. p. 7. —Weatherhead,Synopsis of Nosology, &c.l2rao. 1834 p. 44. EXCRETION AND EXCRETIONS.— (Clas- sif. Pathology — AEtiology — Sympto- matology.) 1. Defin.— Excretion is the separation of substances from the living body; and the secre- tions or substances separated are the fiscal parts of the ingesta, and the matters which have ful- filled their destined purposes in the frame; and which, being no longer suited to, or susceptible of, vital alliances, are eliminated from the blood in gaseous,vapor ous, or liquid states; their discharge being necessary to the continuance of health, and being performed under the influence of life. 2. A knowledge of the various functions excret- ing or eliminating effete matters from the blood, of the manner in which they are influenced by foreign agents, and of their mutual actions and reactions, is necessary to a philosophical and suc- cessful exercise of the healing art. The continued introduction of matters into the frame, and their temporary circulation and assimilation, is coun- terbalanced by a corresponding discharge ; the substances received being, after indefinite periods. excreted in very different states of elementary combination. Matters are introduced into the frame almost entirely by the digestive and respi- ratory surfaces; they are discharged also by these surfaces, and by other channels almost exclusively appropriated to this function. I shall take a view, first, of the several excreting functions ; and, next, of the manner in which their interruption or suppression affects each other, and disorders the vital actions. 3. The Excretions are either—(a) The Na- tural, or those which are ejected altogether from the body, as the fasces, urine, &c; and which may be divided into — a. exhaled, as the transpirations from the skin and lungs; tf. se- creted, as the urine, &c.; and, ■/. facal, consisting not only of exhaled and secreted fluids, but also of those parts of the ingesta which remain after the process of digestion is completed ; — (b) The Morbid, or those — u. which are imperfectly ejected from the circulation, as the fatty matters which accumulate in situations where they do not materially interfere with the vital actions; and, 47.), emaciation appears to have been a prominent symptom; indicating the probable ori- gin of the discharge in the rapid absorption of fat from the adipose tissue. Instances of fat voided from the bowels in large quantities are adduced also by Tulpius (Observ. Med. Amst. 1685.), Arnot (Edin. Med. Essays, vol. v. part ii. p. 652.), Scott (Edin. Med. Comment, vol. iv. p. 334.), Babingtos (Philos. Trans, for 1813. part ii. p. 150.), Mr. Howship (Pract. Observat. in Surgery and Morb. Anat. p. 283.), Culle- rier, E^stcott (Med. Gaz. vol. xii. p. 49.), and Dr. Turner (Trans, of Med. and Chir. Soc. vol. xviii. p. 73.). 17. In the first case detailed by Dr. Elliot- son (Trans, of Med. and Chir. Soc. vol. xviii. p. 76.), the fatty matter discharged was fluid, of a yellow colour, concreted when cold, and burnt with a large flame, like oil. It was gener- ally evacuated with the fasces, in large quantity; and occasionally it ran from the patient involun- tarily. The discharge was preceded by bloody stools, was continued for several months, was attended by great pain, and was associated with phthisis and mellitic diabetes ; pus being thus evacuated from the lungs, saccharine urine from the kidneys, and fat from the bowels, at the same time. On dissection, all the intestines appeared greasy, as if soaked in oil, with numerous black points in their mucous membrane; but there was no other lesion in them. The liver was healthy, and the gall-bladder full of thick dark bile. The pancreatic duct, and large lateral branches, were rilled with white calculi. The kidneys were sound, the lungs tuberculated and ulcerated. In the second case adduced by Dr. Elliotson, the fat was discharged in both a solid and fluid state. The patient died of this complaint and phthisis. No disease was discernible after death, in the alimentary canal or urinary organs. The liver was large and pale, but healthy in struc- ture; and, with the gall-bladder, destitute of bile. D. Prout (Ibid. p. 79.) saw a young lady, who voided, " for many months before death, fatty matter in large quantities, mixed with blood and other things." The caecum was found thick- ened; and the mucous coat of it and of the colon was ulcerated. The other abdominial viscera were healthy. 18. In the first of the cases detailed by Dr. Bright (Trans, of Med. and Chirurg. Soc. vol. xviii. p. 3.), the fatty matter was observed in the stools, in the course of diabetes, on which jaun- dice had supervened from obliteration ofthe com- mon bile-duct, caused by disease ofthe pancreas, with malignant ulceration ofthe duodenum. The second instance of this kind of excretion recorded bv this physician was remarked during jaundice caused also by obliteration of the common bile- duct, owing to disease of the pancreas and ma- lignant ulceration of the duodenum. In the third case, a nearly similar association of morbid phe- nomena, and of organic lesions, to those charac- terising the second, was observed. In the case detailed by Mr. Lloyd (Ibid. p. 57.), the excre- tion of fat in the stools was remarked in the course of jaundice caused by enlarged pancreas; the gall-bladder and hepatic ducts being greatly distended with bile, and the common and pancre- atic ducts obliterated. 19. I was recently called to a married female of about forty, who had never been pregnant, and who complained of symptoms which I attributed at first to the passage of gall-stones along the ducts, and afterwards to a concretion in the bowels. Upon examining the evacuations, with the expectation of detecting something of this kind, two lumps were found, the largest of which was above the size of a walnut. They were of a whitish colour, with a slight greyish green tinge, were greasy to the touch, imparted a permanent greasy stain to paper, resembled adipocire in consistence, and burned with a whitish blue flame and much smoke. After their evacuation, much relief was procured, and the opportunities of ex- amining the evacuations ceased; but the patient, who occasionally calls at my house for advice, still complains of disorder ofthe digestive organs, particularly of the liver and bowels. In the au- tumn of 1833,1 saw, through the kindness of Dr. O'Donnell, a most able physician in Liverpool, a lady who had long suffered chronic disease of the bowels, particularly of the large bowels. The evacuations, which were fluid, contained a num- ber of small lumps, varying from the size of a split pea to that of a bean; but presenting all the char- acters just described. 20. b. The excretion of fatty matter by the urinary organs is more rare.—Dr. Prout, in a communication to Dr. Elliotson, states, that he has seen, several times, a fatty or adipocirous matter voided with the urine; and that, in every instance, malignant disease ofthe kidney or blad- der has supervened, and ultimately proved fatal. Tulpius mentions a case of an old woman who voided fat from both the boioels and bladder, and died remarkably emaciated. Mr. Pearson, in Dr. Elliotson's interesting paper, details the case of a lady of seventy-nine, who, after suf- fering from gall-stones, observed in her stools, which were without bile, a fatty substance, that passed in the form of oil, but quickly concreted; and in her urine a similar oil, which floated on its surface, and concreted like that passed from the intestines. The quantity excreted by the bowels averaged an ounce and a half daily; and by the urinary organs, about the third of an ounce. The patient died emaciated, but no inspection was allowed. 21. c. A case is given, in the Medico-Chirur- gical Review for July, 1*26, from the Annali Universali, of a man who, after irregularities of diet, was seized with vomiting every week or fortnight, for two years. During an unusually severe attack, occasioned by great imprudence in diet, a quantity of pure blood, and a thick oil, or melted fat, were thrown up ; amounting in all to thirty pounds in twenty-four hours. He nearly sunk ; and his skin hung in folds, as thouo-h all the fat had been absorbed. After some time he was restored to health. It is rea- sonably supposed that his fat had been rapidly absorbed during the attack of vomiting, and 844 EXCRETIONS — Morbid. poured into the stomach. Diemerbroeck (Observ. et Curat. Med. Cent. obs. 93.) minutely details the case of a female of twenty-seven years of age, who was long afflicted by violent gastro- dynia, and obstinate vomiting of a black fluid containing lumps of fat of the colour and consist- ence of butter. The bowels were costive; but the uterine, biliary, and urinary functions were not deranged. She was ultimately cured by cathar- tics, enemata, and cordial anodynes. Instances of the ejection of fatty matters from the stomach, after prolonged or repeated vomiting, and without the possibility of a foreign origin, are recorded also in the Philosophical Transactions (for 1673, No. 96.), and by Gesner (Beobachtungen, b. i. No. 10.), Gourrand (Journ. de Med. t. lxxxv. p. 366.), and J. P. Frank (De Cur. Horn. Morb. 1. v. pars. ii. p. 370.) 22. From a consideration of the circumstances attending the excretion of fatty matter from the digestive and urinary organs, in the cases now re- ferred to, the inference that it takes place in one or other of the three modes already stated (§ 16.), according to the nature of the disease in the course of which it supervenes, seems to be well founded. The fact, that the milk-like state ofthe serum of the blood, so often observed, depends upon the admixture of animal oil or fat in it, remarkably favours the inference as to the first and second of these sources of the fat found in the excretions. The opinion entertained by Sir E. Home (Phi- los. Trans. 1813, part ii. p. 150.), and attempted to be proved by experiments, that the fat is formed in the lower intestines by means of bile, is dis- proved by the cases recorded by Dr. Bright and Mr. Lloyd. The passage of bile into the digestive canal was completely prevented in all these. But the inference/that imperfect digestion and assimilation, and the consequent formation of oil in the blood, or the absorption of it from the adipose tissue into the circulation, and its excretion from the blood by the bowels, are the true source of this phenomenon, is fully evinced by the history of these, as well as of the other cases. The presence of oil in the urine, remarked in rare instances, is a further proof of the origin now contended for. There is strong reason to believe that the excretion of superabundant oil in the blood takes place much more frequently than is supposed, by this latter channel. Hippo- crates, Galen, Prosper Alpinus, and sev- eral other writers, noticed it as an unfavourable 'occurrence, and not incorrectly considered it as a symptom of colliquation. 23. B. The most remarkable changes presented by the excretions through natural channels are described in the articles Blood (§ 115. et. seq.), and Disease (§ 99. et seq.), and in the numer- ous articles on diseases in which the excretions are early or principally affected. The more isolated and prominent of them only will there- fore be noticed at this place. — a. The fxcal excretions are either diminished or increased, or otherwise changed ; alterations of these being generally connected with disorder of the hepatic organs. Obstructed or diminished discharge of bile, arising either from torpor of the liver, from congestion, or from obstruction ofthe ducts, &c, deranges not only the intestinal functions and excretions, rendering the latter pale and offensive, but also the digestive and assimilative actions, the urinary and perspiratory functions, and the conditions of the nervous system, occasionally terminating in coma and death; especially when the bile has been taken into the circulation, and has coloured the tissues and exhaled fluids. The bile may be so altered in colour and consistence, owing either to the superabundance of certain of its elements in the blood, or to its remora in the ducts and gall-bladder, and to the consequent changes, as to impart to the faeces a very dark green or almost black colour, even independently of the exhalation of blood in the prima via. I have remarked this uncommon state of the faecal discharges chiefly in diseases impeding respira- tion, as asthma, bronchitis, hydrothorax, and chro- nic affections of the liver. A black appearance of the alvine excretions is, however, more fre- quently produced by the escape of blood into the upper portions of. the alimentary tube; but upon diluting or mixing the evacuation with water, a greenish hue will be assumed in the former case, and a reddish or ochry tint in the latter. The remarkably copious, rice-coloured, wateiy evac- uations in pestilential cholera, are attended with an albuminous coating of the intestinal mucous surface; the serum of the blood having exuded from this surface, owing to deficient vital power of this part, and ofthe frame generally, and to a morbid state (dyscrasy) of the blood itself; its albumen partially concreting on, and adhering to, this surface, as proved by the examination of bodies, in which treatment had not removed it previously to dissolution. The faecal excretions are more or less altered in most diseases; but it would lead to repetitions to pursue the subject further at this place. The excretion of gaseous matters from the alimentary canal is considered in the article Flatulence. 24. b. The urinary excretion varies in quan- tity, influenced by the interruption or abundance — 1st, ofthe respiratory exhalation; 2d, of the cutaneous transpiration; 3d, of the intestinal ex- halations : copious discharges from one or more of these surfaces diminishing this excretion, and opposite states increasing it. The urine may also contain various foreign matters, or certain of its usual constituents in excess; but generally as a consequence of disease. It contains much gela- tine and urea, in typhoid or adynamic fevers; much albumen and phosphate of lime, in rickets; much urea or lithic acid, in dyspeptic affections and gout; and much saccharine matter, in dia- betes. In inflammatory fevers, the urine is red, deep-coloured, or even a deep brown, and trans- parent, until a crisis occurs; when it becomes more copious, and deposits the lateritious sediment, which is of a reddish colour, and consists of phos- phate of lime, lithic acid, sometimes lithate of am- monia, and animal matter, with lithate of soda, and purpurates of ammonia and soda, according to Dr. Prout. In intermittents, it varies with the stage ofthe paroxysm; but, after the seizure, it deposits a red powder, consisting of rosacic acid. In gout and rheumatism, it contains much lithic acid. In hysteria, it is copious, of a pale colour, is deficient in urea and animal matter, and abounds with the usual salts. In jaundice, and other diseases inter- rupting the functions of the liver, the urine pre- sents a brown Or muddy appearance, or contains bile; the kidneys having to a certain extent as- sumed an office vicarious of that of the liver. In EXCRETIONS — Morbid. 845 bilious remittent fevers, it often possesses a simi- lar character. In dropsies, it is sometimes yel- lowish green and extremely viscid. It generally deposits a copious sediment of rosacic acid, lithic acid, phosphate of lime, and animal matter; and in acute dropsy is frequently so loaded with albu- men as to coagulate when heated, or when sul- phuric or nitric acid is added to it. 25. In all inflammatory diseases, the urine is small in quantity and high-colaured, and contains acids in excess; but in disorders of irritation or debility, it is generally pale, in large quantity, and abounds in neutral saline, or alkaline sub- stances. Blood is sometimes found in the urine; and the inky or black colour it presents on rare occasions, most probably is caused by the passage of the colouring matter of the blood along with it from the kidneys, and by the action of the salts contained in it. Dr. Marcet ascribed this col- our to a particular acid, which he called the melanic. In a few cases, the urine assumes an almost gelatinous state shortly after it is voided. I met with an instance of this kind in an advanced stage of pregnancy; severe pains in the loins and sickness being complained of. Antiphlogistic treat- ment removed it. Mucus and puriform matters are also seen in the urine, during and after irrita- tion, or inflammatory diseases, of the kidneys, bladder, or prostate gland. (See Kidneys, and Urine.) 26. c. Vicarious excretion is of frequent oc- currence in several diseases; and takes place to a certain extent even in health; causes which merely diminish excretion in one part, increasing it in others, without manifest disorder ensuing. But no excretion can ever be long, or much interrupted, without disease supervening; the in- creased function, which supplies its place for a while, itself sooner or later passing into disorder of a more or less acute kind and dangerous char- acter. The perspiratory and respiratory exhala- tions are seldom altogether suppressed; but when they are interrupted, one or two things generally ensue:—1st. When the vital powers are not mate- rially depressed, nor any organ disposed to disease, the actions of the kidneys, ofthe liver, and bow- els, are individually or conjointly increased, so as to compensate for the interruption of either of these exhalations;—2d. If such compensation does not take place, or if some organ is disposed to disorder, the vascular system is overloaded by the consequent augmentation of the serous parts of the blood, or irritated by the retention of mat- ters requiring to be excreted; and the predisposed organ becomes congested or inflamed ; fevers, inflammations, &c. supervening, according to in- dividual predisposition and concurrent causes. 27. d. Interruption or suppression of the urina- ry function is one of the most serious occurrences to which the frame is liable, and the least admits of being replaced even for a time by other excre- tions. Yet a compensation sometimes takes place to an extent preservative of life, for several days, or until suppression is removed. In such cases, the exhalations from the lungs, the cutaneous transpiration, and the actions of the alimentary canal, are individually or conjointly increased, so as to supply the deficiency; and the urinous or ammoniacal fetor of the breath and perspiration often indicates that the excretion of urea and other injurious matters is effected chiefly by the 71* cutaneous and pulmonary surfaces. In some instances, a urinous fluid, or rather fluid con- taining urea and the salts usually found in the urine, is exhaled in considerable quantity during the repeated or prolonged vomiting that often attends disease of the kidneys with suppression of urine ; and, in other instances, the intestinal discharges become watery, urinous, and abun- dant. When the suppression is complete, much more serious results follow: a urinous spedes of fever supervenes, owing to the retention in the blood of an excess of serum holding alkaline and highly azotised salts in solution, and to the ac- tions of other excreting organs being insufficient to compensate for the suppression. In such in- stances, the pulse is accelerated, large, full, and oppressed; the perspiration copious and offensive; the soft solids and muscles flaccid ; the bowels irregular or relaxed, and the stools morbid and fcetid ; the countenance and cutaneous surface foul or lurid; and the foetor ofthe patient's apart- ment often remarkable. These cases generally terminate in coma, or sudden death, with or without convulsions, owing to the influence of the impure blood on the brain; and in effusion into serous cavities: but similar terminations of in- terrupted urinary excretion sometimes take place without antecedent urinous fever. In a very hope- less case of this form of fever, in the cook of a friend's family, the secretion of urine, which had been suppressed entirely for several days, was restored by cupping repeatedly on the loins, and by diuretics, purgatives, and deobstruents. The abundance and fcetor of the exhalations from the lungs and skin were very great in this case. 28. e. Interruption of the biliary excretion may continue for a long time without a fatal result; but whether the secretion be suppressed, or the discharge of it into the intestines prevented, se- rious consequences usually ensue, although the bile may not pass or be absorbed into the cir- culation. If the secretion does not proceed, the other excretions become morbid, particularly the faecal and urinary; the breath and perspiration are offensive; the skin sallow or lurid; digestion and assimilation are interrupted; and, in the pro- cess of eliminating those matters from the blood, by which the organs are irritated, additional dis- ease is excited, and complications induced. Thus the alimentary canal, lungs, kidneys, as well as the liver, often become affected. Even when bile is secreted, its discharge being prevented by ob- struction of the ducts, the part of it which passes into the circulation is frequently so far removed by the kidneys and skin as to prevent, for a con- siderable time, any change in the blood sufficient to destroy life. (See Disease, § 162. 168.) 29. /. Protracted or frequent interruption of the facal excretions are generally in some degree compensated by an increase of the cutaneous and pulmonary exhalations and of the urine, and serious effects are thereby prevented for a time. These vicarious excretions are generally very offensive, owing to the quantity of effete animal matter carried off in the exhaled vapour; and they not infrequently excite dangerous disease of the organs by which they are principally effected. In a case of stricture of the transverse colon, at present under my care, with nearly complete ob- struction of faecal excretion, pulmonary disease has 1 been superinduced ; the kidneys having become 83 846 EXPECTORATION —Mnco —Albuminous. the chief excreting organs, and their actions greatly increased. Of the other vicarious excretions, it is unnecessary to add any thing to what is stated in the articles Disease (§ 162. et seq.), Hjsmorr- hage, Menstruation, and Symptomatolo- gy; topics which have not been alluded to at this place, being considered in those articles to which they more especially belong, and where their practical importance is fully estimated. 30. g. The practical indications furnished by the excretions in their increase, diminution, and alteration, as well as in their reciprocative rela- tions, are most important in the management of disease. It is shown in various places, that one of the earliest effects of the exciting causes of disorder is the interruption or suppression of one or more of the excreting actions; it therefore fol- lows, that the restoration of the interrupted func- tion should be a principal indication of cure. The diversified and ever-varying states of the several excretions ought, in addition to the estimation of quantity, to be made subjects of attentive and daily examination; as furnishing, when interpret- ed aright, the surest proofs of existing disorder, and of the operation of medicines, as well as the firmest basis of rational or philosophical practice. The effects of impeded excretion on the blood and on the nervous system should be carefully watched and considered; and such as most ob- viously result, although often unaccountably over- looked both by writers and by practitioners — especially vascular fulness, local or general, with more or less of deterioration of the circulating fluids — ought to be prevented or removed by means appropriate to the peculiarities of the dis- ease, and of the circumstances in which it is observed. (See Physic — Practical Prindples of) Biblioo. and Refer.—J. M. Savoranola, De Eges- tionibus, App. ad Pract. de Feb. 8vo. Lugd. 1560.—J. B. Montani, De Excrementis, I. ii. Venet. 1566, 8vo.—Spac- chius, De Expulsione et Retentione Excrement. Arg. 1597. —R. A Fonseca, De Hominis Kxcrementis. P sis. 1613.— Horst, De Causis Syrap. Qualitalis inutatap et Retentorum atque Excretorum praeter Naturam. Witeb. 1687.—Boer- haave. De Utilitate inspiciendorum in -Egris Excremento- rum, &c. Lugd. 1693.—Juncker, De Salutari Excretionum Promotione. Halae, 1746.—Salzmann, De Secretionis atque Excretionis Necessitate, Utilitate, atque Noxis. Argent. 1737.—Gumbrecht, De praecipuis Morbis, qui ex Interceptii Excrclionibus proficiscuntur. Htlmst. 1769.—Ludwig, De Immoderatis Kxcretionibus, Causa Dcbilitatis in Morbis. L ps. 1763.—Vogel De Hegimine Secretionu.-n et Excre- tic num. Helmst. 1766.—Wahnschnft, De Excretionum qua- rundam Coinpqgisntione. Arg. 1777.—Goldhagen, De Valore Eccrisium rite .Sistimanda. Hala?, 1786.—Cartheuser, De No ia Retinendorum Excretione, et Excernendorum Re- tentione; in Diss. Select. No. 11.—Chaussier et Adelon, Diet, des Sciences Medicales, t. xiv. p. 3 —Prout, On the Diseases of the Urinary Organs, 8vo. Lond. 1826, 2d ed.— Author, in Appendix to Trans, of Richerand's Elements of Physiology, 2d edit. p. 593. et 627. et seq.—Rostan, Mtde- cin'e Cl ni'que, Stc. t. i. p. 150.—F. Tiedemann, Systematic Treatise of Comparative Physiology, kc translated by Gully and Lane, 8vo. Lond. 1834, p. 202. et passim.—See also the Bibliography and Rbferences (ii.) under the arti- cles Disease, and Symptomatology. EXPECTORATION (from Ex and pectus). —Classif. Pathology — Symptomatology. 1. This word, which signifies the act of dis- charging any substance from the chest, is now usually applied to the matters so discharged. The secretion which moistens the surface of the bronchi is a colourless and somewhat viscid fluid, consisting chiefly of the serum of the blood, and a modified, peculiar, or slightly glutinous form of albumen. It is so scanty in health, as to be sel- dom or very rarely excreted: but in disease, its quantity varies very much; it being commonly — occasionally, remarkably — increased, excepting at the onset of some inflammatory or exanthema- tous complaints, when it is diminished, and then only for a short time. Its quality or appearance is also extremely different, in different maladies, and even in different stages of the same malady, seated in or implicating the respiratory or circulat- ing organs; particularly as regards the quantity and condition of the animal matter or albumen which it contains. The saline substances found in the serum of the blood also exist in it, but in various proportions ; they being usually more abundant in haemorrhagic and inflammatory dis- eases of these organs. 2. A. The appearance and quantity of the ex- pectorated matter are amongst the surest rational signs of the progress and state of several diseases ofthe chest, especially bronchitis and pneumonia; and in many instances they alone furnish sufficient grounds of both diagnosis and prognosis. They should, therefore, whenever the functions of res- piration are disturbed, or when the bronchial se- cretion is any way altered, be carefully inspected. For this purpose the sputum ought to be collected in two glass vessels; one of which should be pre- viously nearly filled with clear water, in order that it may be examined both alone and on the surface of water. The periods of expectoration should also be noted, with the frequency and na- ture of the cough, and the degree of difficulty attending the excretion. 3. a. The colour of the sputum varies, in pul- monary diseases, from the colourless and trans- parent or diaphanous, and viscid or glairy fluid of the early stages of bronchitis, through every possible shade, to the blackest hue exhibited in melanosis or in gangrene of the lungs. The ex- pectoration is partly yellowish and opaque, and partly mucous, pituitous, and serous, variously mixed, in chronic bronchitis ; and it is yellowish, greenish, greenish yellow, slightly mixed with blood, red or rusty, in pneumonia. Its colour is ash-grey in phthisis, and blackish in the rare states of disease just mentioned. But healthy per- sons often expectorate mucus so intimately mixed with the carbonaceous particles usually floating in the air of large towns and factories, as to resem- ble the sputum in melanosis of the lungs. 4. 6. The savour ofthe expectoration is by no means constant in the same disease. It is some- times sweetish or saltish, or intermediate, in phthi- sis and haemoptysis. The odour oi the sputum is sometimes disagreeable in chronic bronchitis, and in the ulcerated stages of phthisis; in which latter it is often fcetid; but it is much more so in gan- grene of the lungs and pleura, and in the last stage of abscess of the lungs. Increased warmth of the sputum is not readily perceived, although it may exist in inflammatory affections of the lungs. Diminished warmth indicates dangerous or fatal sinking of the vital powers. 5. c. The form of the sputum is important; and is chiefly owing to the manner in which the mor- bid secretion is excreted; and to the quantity and modification of the albumen existing in it. When it is frothy, it may be inferred to have been ex- pectorated with difficulty, and with severe cough: it then is generally fluid, glairy, transparent, con- EXPECTORATION — Bloody — Mtjco-purulent, &c. 847 tains albumen, and runs into one mass in the con- taining vessel, to the sides of which it adheres slightly; as in catarrh, the early stages of bron- chitis, &c. When it is viscid, opaque, somewhat frothy, and thick, it is usually brought up with much cough, contains much more albumen, ad- heres closely to that previously expectorated and to the sides ofthe vessel, and results from acute inflammation of the smaller bronchi and sub- stance of the lungs. When it is rounded and isolated, it is expectorated more easily, as in ad- vanced stages of pneumonia; and when it is thick, opaque, rounded, distinct, and muco-puri- form, or purulent, it is also brought up with more ease, and proceeds from organic change of the substance of the lungs, as in certain states of phthisis, &c. 6. d. The consistence ofthe sputum is of much importance. WThen it is watery and serous, it generally proceeds from simple increase of the exhalation from the air-passages, without inflam- mation of, or merely with simple determination to, the bronchial surface; but this kind of expec- toration may accompany phthisis, chronic pleu- risy, and other thoracic diseases not seated in the bronchi. A mucous and transparent fluid is expectorated in catarrh, and in slight affections of the throat,-but it also frequently attends the diseases of the chest just mentioned. Viscid, thick, and adhesive sputa, containing much albu- men, characterise acute inflammation of the lungs. A membranous or tubular substance, with thin, viscid, or puriform mucus, is often discharged in croup, and consists chiefly of albumen, sometimes approaching the fibrinous state. In rare in- stances of sub-acute bronchitis, albuminous con- cretions, solid or tubular, and of an arborescent form, moulded in the ramifications ofthe bronchi (Bronchial polypi), are expectorated during the decline of the disease. Cases of this description are recorded by Tulpius, Dalbis, Cons- bruch, Bussures, Sambf.r, De Haen, Wahren, Callisen, Strack, Dixon, Acharius, Cheyne, and Iliff. 7. The quantity oi expectorated matters varies extremely. At the commencement of inflam- mations it is but little increased; but is augmented with the progress of disease, and diminished as disorder subsides. Suppression of the expec- toration, especially when sudden, the pulse con- tinuing frequent and the other symptoms uname- liorated or exasperated, is a very dangerous circumstance. The more watery or thin the consistence, the more copious is the expectoration, as in bronchitis and bronchorrhoea; and the more thick, opaque, or dense it is, and the smaller the quantity compared with the severity of the other symptoms, the more seriously is the substance of the lungs diseased, as in pneumonia and phthisis. In many cases ofthe worst states of these diseases, the sputum is very scanty to the close. 8. Bloody expectoration is a serious appearance; but it is of importance to ascertain its origin, and to consider it in connection with all the pheno- mena. An exudation of blood from the nasal fossae, from the posterior fauces or pharynx, or even from the gums, may take place, either so as merely to tinge the surface of the sputa, or to the extent of constituting a dangerous haemorrhage. In these cases, the blood is not frothy, and is not mixed with the matters brought up from the air- passages. If the expectoration be thin, frothy, ropy, and only streaked with blood, the fits of coughing are generally the cause of the bloody appearance. If the blood be mixed in a ropy, opaque, or puriform mucus, very acute bronchial inflammation is usually present; and if it be seen in spots in thick, opaque sputa, acute inflam- mation ofthe smaller ramifications of the bronchi, often extending to the substance of the lungs, may be inferred. When the blood expectorated is very abundant, or nearly pure (hamoptysis), it may proceed from simple exudation from the bronchial surface, or from organic changes ofthe lungs, heart, or large vessels. (See Hemorr- hage and Lungs.) 9. When the blood is simply exhaled from the air-cells ofthe lungs, it is florid and frothy, and more or less abundant. If the sputa be only tinged with blood, or reddish, and thick, viscid, adhesive, or slightly frothy, pneumonia is cer- tainly present. If the expectoration become ochry, rusty, reddish brown, livid, and rounded, purulent infiltration, hepatisation in an advanced stage, or some other most dangerous organic change of the lungs, exists. Bloody sputa, but of no constant form, also attend the effusion of blood in the parenchyma of the lungs, and phthisis. The appearance of blood in the sputa, late in pulmonary diseases, or in very minute quantity, is of much more serious import, than in an early stage, or in large quantity. 10. C. Purulent expectoration, of a pure and unmixed kind, is much less frequent than is com- monly supposed; what is usually considered purulent, being a mixture of puriform matter with mucus, and a product of inflammatory irritation in the bronchi. As a symptom of phthisis it deserves little attention, as this disease may be present, and even run its entire course, without its appearance : and it may be most re- markable, particularly in very young subjects, in the slighter pulmonary affections, as in chronic bronchitis, in the decline of severe catarrh, and in hooping-cough; in which latter, the morbid secretion in great part proceeds from the poste- rior fauces, pharynx, and their vicinity. When observed in phthisis, it is owing commonly to associated chronic bronchitis, or to the com- munication of a tubercular excavation with the bronchi, the puriform matter being secreted by the irritated surface of these tubes. But pus is seldom or never seen in a pure state, and unmixed with mucus, unless when a large vomica, or abscess, either formed in the paren- chyma of the lungs, or extending thither from the liver, bursts into the bronchi. In this case, the matter, variously tinged, is friable, often foetid, does not retain air-bubbles, and sinks or diffuses itself in water. When mixed with mucus, as in other pulmonary diseases, it does not pre- sent these characters, excepting in a very partial and variously modified form, as shown in the articles Bronchi, and Lungs. When an abscess forms in the lungs, which is a comparatively rare occurrence, and bursts into the bronchi, the pus expectorated is generally in very large quantity; the expectoration continuing until the abscess is partially emptied; when it frequently altogether ceases, and again returns in great abundance when the cavity is refilled; the intervals often extending to several days. In these cases, the 3 id EYE—Inflammation of—Causes. matter is yellow, whitish yellow, yellowish green, or reddish yellow ; presents all the characters of pure pus, excepting in the intervals when the more scanty sputa is generally mixed with mucus; and ultimately becomes more offensive, and as- sumes deeper shades of colour. I lately attended a case where abscess formed in the substance of the right lung presented these well-defined char- acters : yet the patient never coughed during its formation—although it was so large as to bulge out the right side of the thorax — nor until the time of its bursting into the bronchi. 11. D. The appearance of fine, white streaks ; or the presence oiivhitish, or whitish yellow, small masses, like boiled rice, in a mucous or muco- puriform sputa, generally indicates the softening of tubercles : but the earlier and more advanced stages of phthisis are attended by the very vary- ing state of the expectoration described in the article on that malady. Sabulous, calculous, or earthy mutters are sometimes expectorated in certain states of pulmonary or phthisical disease ; but these matters do not indicate the most dan- gerous forms ; for I have known several cases where recovery took place after their discharge. The presence of hydatids in the expectoration is very rare.—Substances that are swallowed, are sometimes coughed up from the trachea, through an ulcerated communication formed between it and the oesophagus. Zeviani records a case of this kind ; and one was, a few years since, atten- ded by Mr. Byam and myself. The various modifications of the expectoration, during the pro- gress of pulmonary diseases, are minutely describ- ed in the articles Bronchi, Hemorrhage, Lungs,and Tubercular Consumption; and the indications derived from this source are there duly pointed out. BlBLlOQ. and REFER.—Hippocrates, Aphorism, set. vii. 15.—Blum, De Sputo. Bas 1, 1622.—Bussures, in Phi- los. Trans, n. 263. p. 545.—Samber, in Ibid. n. 39?. p 262. —H.benst,-eit, De Sputo Critico. Lips. 1749.—Rinck De Spulo ut Signo in Morbis. Hard. 1764.—Webel, De Sputis, in Die-lag's Tract, vol. i. p. 70.—Callisen, in Acta Reg. Soc. Med. Haun. vol. i. p. 69. et 76.—Warren, Trans, of Coll. of Phys. vol. i. p. 407.—Portal, Memoires de l'Acad. de Paris, 1780.—De Hien, Ratio Med. pars. ix. p. 49.— Consbruch, Observ. Med. Stuttg. 1777.—Dixon, Ed. Med. Coinm. vol. ix. p. 254. —Dulbis Journ. de Med t. xi. p. 42. 370.—Zeviani, n Mem. di Matematica e Fisica, t. vi. Verona, 1792.—Strack, in Hufeland's Journ. d. Pract. Arineyk. b. v i. p. 162.—A-harius, Lond. Med. and Phys. Journ. vol. viii. p. 201.—C. Darwin, in Ibid. vol. iii. p. 374.; et. vol. iv. p. 49. 108. 203. -Valentin, Journ. de Me . Contin. t. xiv.—Pearson, Philosoph. Trans. 1809.—Cheyne, in Edin. Med. and Surg. Journ. vol. iv. p. 441.—linyle, Sur la Phthisie Pulmonaire, p. 26.—Double, Semeiologie Generale, kc t. iii. p. 81. et sea.—Laennec, Auscultation Mediate, by Forbes, passim—Andral, Clinique Medicale, I. ii. et i i. passim.—Iliff Lond. Med. Repos. vol. xviii. p. 207.—Rostnn, Cours de Med. Clinique, &c. t. i. p. 416.— C. J. B. Williams, Cyclop, of Pract. Med. vol. ii. p. 127. EYE, DISEASES OF THE. —Syn. 'o,r:\u.uo; Oculus. Das Auge, Germ. CEi/, Fr. Occhio, Ital. Classif. Special Pathology — Mor- bid Structures. 1. The progress of knowledge, in respect of dis- eases of the eye, has been very remarkable since the end of the last century; owing chiefly to the re- searches and writings of Beer, Schmidt, Him- ly, Scarpa, Benedict, Demours.Edmond- ston, Vetch, Wardrop, Wellf.r, Trav- ers, Guthrie, Mackenzie, and Lawrence. In the account that will be here given of these diseases, those only which ara inflammatory, and j I consequent upon inflammation, will be considered. Functional disorders are treated of in separate articles. (See Amaurosis, Sight, &c.) The order in which these maladies will be discussed, will differ but little from that adopted in the truly valuable worksofMr. Lawrence and Mr. Mvc- kenzie; to which I have much pleasure in stat- ing my obligations.—The latter of these writers, and J. Frank, treat first of the diseases of the eyelids and lachrymal apparatus, and next of the : eye itself. Mr. Lawrence enters at once upon j the consideration ofthe inflammatory diseases of ! the tissues ofthe eye-ball, and concludes his clas- sical production with those of the appendages. Either arrangement is unexceptionable; but I shall follow the latter, merely as being more congruous with the medical view of the subject, to which I shall chiefly confine myself. The surgical treat- ment of such of those diseases as require it, must be studied in the works now referred to, or in Mr. ( Cooper's Surgical Dictionary. I shall, there- fore, first treat of inflammations affecting the ex- ternal coats of the eye, and afterwards of those attacking the internal tissues of the organ. [. Inflammations of the Eye.—Syn. Oph- thalmia; Lippitudo,Celsus; Augenentziindung, Germ.; Ophthalmie, Fr.; Ottalmia, Ital. Classif.— 1. Class, 2. Order (Cullen). 3. Class, 2. Order (Good). III. Class. I. Order (Author). 2. Defin.—Pain in one or both eyes, with vascular injection of one or more of their con- stituent tissues, and constitutional disorder. 3. Inflammations of the eye are of various grades and kinds: they commence in any one of the different tissues forming the organ ; and they are thus limited more or less, and for a longer or shorter period of their course, according to the temperament, habit of body, and diathesis of the patient; to the state of predisposition, and the nature of the exciting causes ; and to the treat- ment adopted. Before considering separately the different varieties of ophthalmia, I sha\\ first take a general view of their causes ; and next oi the numerous forms they present, owing to the varied concurrence of predisposing and exciting causes. 4. i. Causes.—A. The predisposing causes oi inflammation of the eye are nearly the same as those of inflammatory diseases of other organs.— (a) Temperament, idiosyncrasy, and consequently hereditary disposition, evidently favour its occur- rence. The colour of the eye has apparently but little influence, for Dr. Smith found the re- lative proportion of cases in light eyes nearly the same as in dark eyes. — (b) Morbid diathesis, especially the scrofulous, has the most remark- able effect, and next the gouty and rheumatic. These not only dispose to, but also modify, the disease and its consequences, and require for it appropriate modes of treatment.—(c) It is diffi- cult to determine how far age and sex have any influence ; but advanced age certainly favours the supervention of chronic inflammation of this organ.—(d) Climate has a much more manifest effect. The excessive cold, and reflected light, in hyperborean regions ; and the great warmth, dryness, and reflected heat of some countries, especially Egypt, Arabia, &c, heightened by the quantity of fine dust floating in the atmosphere ; not only predispose to, but excite, ophthalmia.— («) Great exertion of the eyes occasions disease of EYE—Inflammation of — Varieties and Forms of. 849 them; but chiefly when aided by too full living, by the use of stimulating liquors, and by an im- proper manngement of light, in respect both ofthe objest on which the sight is exerted, and of the eye itself. — (/) Various occupations, consequently, are very liable to ophthalmia ; as engraving, watchmaking, wool-sorting, and the manufacture of minute objects.—(g) The suppression of accus- tomed discharges, as ofthe catamenia and haemor- rhoids, and an impeded return of blood from the head, favour the supervention of inflammation of this orgnn, by occasioning cerebral conjestion.— (h) A plethoric habit, and particularly fulness of blood in the head, are very common predisposing causes; and often exist in connection with the pre- ceding.—(i)Impaired constitutional power is most influential, especially during convalescence from exanthematous diseases.— (k) An unhealthy or cachectic state, owing to impaired digestive, assi- milative, and excreting functions, has also a most marked effect, and is often further associated with local or general plethora; particularly in those addicted to spirituous or fermented liquors, or who lead a sedentary and indolent life, or live in close, smoky, crowded, and unhealthy situations, or are subjected to anxiety of mind and other depressing passions.—(/) Too full or rich living, errors in diet, and the inordinate indulgence of the appe- tites, frequently predispose to ophthalmia by inducing plethora, and consecutively hepatic and cerebral congestions, imperfect secretion and excretion, torpor of the biliary and intestinal functions, and ultimately a morbid state of the circulating fluids and disordered vascular action. — (m) Inordinate indulgence ofthe sexual pro- pensities has often a powerful influence, es- pecially in connection with any of the preceding causes; the eyes sympathising remarkably with the generative orgins. 5. B. The exciting causes of ophthalmia are numerous and diversified. Injuries inflicted on the eye, its appendages, or parts adjoining ; wounds of a filament of the ophthalmic branches ofthe fifth pair of nerves; carious teeth; the pre- sence of dust, or minute foreign bodies, between the surface ofthe globe and the eyelids; the irri- tation produced by acrid, stimulating, or chemical bodies, whether in the form of powder, fumes, or vapours; stimulating, acrid, or caustic appli- cations to the organ; operations on the eye, or on adjoining parts ; the introduction of contagious secretions, as the gonorrheal discharge, or the matter of purulent ophthalmia; excessive exer- tion of the eyes, especially with artificial light, at late hours, or with the head held low, and on bright or minute objects; an impure, smoky, or fuliginous atmosphere, particularly in manufacturing towns, crowded and close streets, confined dwellings, poor-houses, hospitals, and the low cabins of the peasantry; the fogs of large cities, which pre- vent the smoke and vapours from rising in the atmosphere, and from being otherwise dissipated; exposure of the eyes to cold, or to currents of air; riding in an open carriage, or in a close carriage with the face to the horses and the carriage windows open; and too full living, or the abuse of intoxicating liquors; are the most common causes of ophthalmic inflammations. The eyes, moreover, participate with other parts, frequently in a very remarkable degree, in the inflammatory state characterising the exanthe- | mata; and hence certain specific forms of ophthal- mia hereafter to be noticed. 6- The modes in which these causes act are sufficiently obvious : but there are one or two that require a more particular notice. Exposure to light is injurious — 1st, by its sudden or power- ful impression; 2dly, by its combination with heat, as in glass-houses, founderies, forges, &c. ; and, 3dly, by being reflected or refracted. Owing to this last circumstance, certain colours, espe- cially red and orange, or the simultaneous im- pression of a variety of colours, or their rapid succession, irritate the eyes in a very remarkable manner. The reflected light from snow has also | a very great effect; and from which the Tartars protect themselves by wearing spectacles of closely netted black horsehair; and the Esqui- j maux by an excavated piece of light wood, with a narrow slit corresponding with the fissure be- tween the eyelids, and blackened on the inner or concave surface. Reflected light attended by high temperature is equally injurious. The glare from the white chalky roads in some parts du- ring summer, and from the white houses and sandy surfaces of some warm countries, is a very frequent cause of ophthalmia. Another and a hitherto unrecognised cause, particularly of in- flammation of the internal tunics, is reading, writing, or otherwise exerting the eyes, by the light refracted by ground glass shades placed around the flame of lamps used for illuminating rooms. About fifteen years ago, I was affected with slight inflammation of the internal tunics of the eye; but having fully ascertained its cause to have been the use of a table-lamp of this de- scription, it soon subsided upon adopting suitable treatment and a different kind of light. I have since had no return of the disease, although I have continued for many years to read or write from eight o'clock in the evening till two or three I in the morning.* The intimate vascular and I nervous connection of the eye with the brain causes it to participate in several of the inflam- I matory states of the latter. Hence those causes which excite increased vascular action, or con- gestions, in the brain or its membranes, both i predispose to and excite similar affections of the eye, especially of its internal tunics. In a per- fectly healthy state ofthe system, a single exciting cau-ie seldom occasions the disease, unless its operation be long continued, or very intense. It is the co-operation of two or more causes, or the action of several in quick succession, that is most injurious. But when the system is rendered susceptible of their impression, by the prolonged or continued influence of the predisposing agents, either of the more immediate causes, although acting singly, will frequently take effect. 7. ii. The Varieties and Forms which in- flammation of the eye presents, are very diver- sified. The severity or acuteness ofthe symptoms, * I write, and generally read, at a desk placed sufficiently high to prevent the head from being held low; and use two lamps with single wicks, the flames of which arc equal to two large wax candles, and which are raised so high that the eyebrows and eyelids completely shade the eyeballs from the light. These are fed with the finest sperm oil', and, the flame being duly adjusted, they burn eight hours, without any diminution of their light, and without requiring to be once touched. The chief advantages of thi. light are its soft- ness and clearness, the permanent height at which it remains, and the entire absence ofthe smallest trouble. 860 EYE — Inflammation of the Conjunctiva. and the rapidity of the progress, of ophthalmia, vary from the slightest increase of vascular injection and action, and the most prolonged continuance, up to the most violent and rapid states in which inflammatory action is ever mani- fested. Hence the conventional terms of acute, chronic, and sub-acute or intermediate, are to be viewed with due latitude as to their import. But ophthalmia, like other inflammations, may be modified in kind or form, as well as in grade and duration, owing to peculiarity of constitution, morbid diathesis, the manifestations of vital power, and the state of the circulating fluids. Thus, ophthalmia in the scrofulous, gouty, or rheumatic diathesis, is different from that affecting sound constitutions; and that occurring in the course of, or subsequent to, the exanthemata, or during typhus fever, or after the passage of purulent matter into the circulation, is individually differ- ent from either of the foregoing, although the grade of action and of vascular injection may be apparently the same in all. I cannot, therefore, agree with Mr. Lawrence, when he infers that no such distinctions as sthenic and asthenic actu- ally exist ( Treatise, fyc. p. 66.). This conclusion is the result of considering inflammation merely as increased vascular action, and without refer- ence to the state of local and general vital power. But the phenomena, the progress, and the results of inflammation, in the various forms and circum- stances in which it occurs, as well as the effects of treatment, show, that excited vascular action does not imply increased power ; and that the former often exists, not only without the latter, but even with a diminution of it, as fully shown in the articles Disease, Erysipelas, Fever, and Inflammation. 8. Ophthalmia differs in degree, at different periods of its course. Thus, it may be slight and prolonged, and suddenly become most violent, acute, and rapid ; or, from the latter, it may lapse into an indolent, slow, or chronic form ; owing to various contingent causes, to consti- tution, and to the treatment adopted. It is also remarkably modified by the tissue in which it is seated; by the nature ofthe predisposing and ex- citing causes ; by its supervention upon, or com- plication with, other morbid states, or specific forms of disease; and by the age, habit of body, and regimen of the patient. Out of these cir- cumstances arise the numerous varieties distinctly established by modern writers, and recognised by every observing practitioner, and the arrangements of them adopted in recent systematic works. The importance of divisions of this subject is shown by the different consequences or terminations usually observed to belong to each of the varie- ties, and by the modified treatment they indi- vidually require. Without carrying the subdivi- sion as far as J. Frank, or too far for practical purposes, I shall first consider inflammation of the external tissues of the eyeball, next those seated in the internal tissues, and lastly the much more rare occurrence of inflammation ofthe whole eye. In treating of inflammation of each of the tissues, its common form will be first described and afterwards those spedfic or modified kinds, it occasionally assumes from peculiarity of cause or of diathesis. II. Inflammation of the External Tis- sues of the Eye. —L Of the Conjuncti- va.— Syn. Conjuncttvitis, Mackenzie ; Ophtludmia, of numerous writers. 9. Charact.—Redness, from increased vas- cularity of the external coat of the eye, with pain, tumefaction, and febrile disturbance of the sys- tem ; the enlarged vessels shifting thdr place with the motions of the eyeball or eyelids. 10. The muco-cutaneous membrane that cov- ers the insides of the eyelids, and anterior third of the eyeball, may be inflamed in particular parts, or throughout its extent, in every grade of severity, and for various periods of duration. When this membrane is inflamed, the vessels are comparatively large, tortuous, and of a scar- let colour. They anastomose very freely, or form a network over the white of the eye, and are drawn aside by dragging the eyelids, or moved by rolling the eyeball; whereas, when the sclero- tica is inflamed, the vessels are small, straight, of a pink hue, and unsusceptible of motion, either by dragging the eyelids or rolling the globe. When, however, the inflammation is so severe that chemosis exists, or the conjunctiva becomes tumid, and the discharge copious and muco-puru- lent, this distinction cannot be made, nor, indeed, does it altogether exist, as the inflammatory action from contiguity extends more or less to the sclerotica, and even to the iris and the cornea. A. Mild Inflammation of the Conjuncti- va.— Syn. Catarrhal Ophthalmia, Law- rence; Conjunctivitis puro-mucosa atmosphe- rica, Mackenzie; Conjunctivitis catarrhalis. 11. a. I have adopted the appellation employ- ed by Dr. Jacob as the most appropriate; for, although the disease is generally caused by ex- posure to cold, yet it sometimes also arises other- wise. It is most common in spring and autumn; is sometimes epidemic ; affects young persons oftener than adults; and frequently attacks most of the members of a family, or, when it appears in a school, a large number of children. Ex- posure to currents of cold air, or to the night air; north-east or easterly winds, and other atmos- pheric influences; damp feet; intoxication; fogs, smoky apartments, irritating vapours; and dis- orders of the digestive organs ; most commonly occasion it. A person who has once experienced an attack, is very liable to a return of it; and I believe, with Mr. Mackenzie, that, in the most severe cases, when the discharge is puriform, it may be propagated by contagion ; the disease then passing into the purulent and severe form. 12. 6. Symptoms.—This form of ophthalmia seldom extends deeper than the conjunctiva. It may be confined chiefly to the lids (Blepharo- conjunctivitis catarrhalis) ; and may affect also the globe (Ophthalmo-conjunctivitis catarrhalis). It commonly commences in the eyelids, or circum- ference of the globe, and extends gradually to the cornea, with a sense of stiffness, smarting, dryness, and as if dust had got into the eye. The intol- erance of light and pain are slight; and the secre- tion at first is diminished, but it is soon succeeded by watering and increased redness. When more fully developed, the redness is superficial, some- what irregular, of a bright scarlet; and the en- larged vessels are superficial, and are readily pushed aside by pulling the eyelids. In the most severe and acute cases, the membranes become generally and uniformly red ; sometimes with spots of ecchymosis, or with minute vesicles or EYE—Purulent Ophthalmia. 85] pustules near the margin of the cornea. There is very little swelling, and rarely any chemosis. An increased mucous discharge, which is at first thin and colourless, but afterwards yellowish or whitish, proceeds from the inflamed surface; but it is seldom in considerable quantity, unless in the most severe cases, when it is copious and muco-puriform. Inflammatory irritation fre- J|aently also affects the lining membrane of the rontal sinuses and antrum, occasioning pain and sense of weight in these parts. The patient com- plains of chills, of headache, exacerbations of fever, especially towards night, of impaired ap- petite, and of sickness or disorder of the stomach. The tongue is generally loaded, and the bowels constipated. 13. c. TerminationsandPrognods.—The symp- toms continue for three or four days; or, under unfavourable circumstances, for a longer time; but they generally yield to treatment, and gra- dually subside; the secretion becoming more puriform and thick, but less copious, until the affection disappears. If the inflammation be very violent, or improperly treated, or if it occur in the scrofulous constitution, or in persons imperfectly nourished, or of dirty habits, considerable che- mosis may ensue, and, the sclerotica and cornea may also become inflamed; causing opacity, or even ulceration, of the latter; and giving rise to a copious puriform discharge, capable of pro- pagating the disease, if introduced into the eye of a sound person. When catarrhal ophthalmia has been severe or of long duration, or has frequently recurred, the palpebral conjunctiva experiences change of structure, and becomes thickened, with elevations or granulations on its surface. The lower lid generally suffers most; the granulations being, according to Dr. Eble, more numerous in the folds of the membrane between the globe and lid, than on the lid itself. Catarrhal ophthalmia, also, particularly in chil- dren of scrofulous constitutions, is liable to de- generate into the pustular or phlyctenular form of strumous ophthalmia. 14. d. Diagnosis.—The very slight pain and intolerance of light, although the vascularity be great; the superficial and scarlet redness of the membrane; the diurnal remissions, and evening exacerbations; the motion of the superficial and enlarged vessels; and the natural state of the sclerotica; distinguish this variety from common inflammation ofthe external proper coats, or ca- tarrhal-rheumatic ophthalmia. But the one af- fection may nearly approximate, or even run into, the other, in the most severe cases. The catarrhal origin, and usually mild character of this affection, and the mucous secretion, are the only circumstances which really distinguish it from purulent ophthalmia; the severer states of the former and the mildest of the latter being so nearly allied that they be justly viewed as merely grades of the same disease. 15. e. Treatment.—In the mildest states of the affection, smart purgatives, diaphoretics, and low diet are sufficient to produce a cure. If the tongue be loaded, an emetic is of service. In more severe cases, local depletion, followed by an emetic, purgatives, and diaphoretics, is neces- sary. Venaesection is required only in the most acute states, occurring in young or plethoric persons, and when both eyes are attacked. When the affection is connected with disorder of the digestive organs, it is readily removed by an emetic, by calomel and James's powder at night, by an active cathartic the following morning, and by sudorifics, aided by diluents, and warm poppy fomentations to the eye. When the in- flammation is considerable, and not readily re- moved by these means, local depletions should be repeated, a blister applied to the nape of the neck, and purgatives, diaphoretics, and low diet persevered in. I agree with the German writers in considering warm applications to the eye pre- ferable to cold, where the affection is produced by exposure to cold: but, when it is otherwise caused, and when the heat and smarting are con- ! siderable, cold washes are agreeable and gene- rally beneficial. When the eyelids are gummed together in the night, a little spermaceti, or any other mild and fresh ointment, should be inserted between their edges in the evening. 16. Mr. Lawrence considers that this affec- tion is one of those to which the application of strong astringents is most appropriate, especially if the inflammation do not extend beyond the mucous membrane; and those who more par- ticularly recommend this treatment, believe that it may advantageously supersede general remedies, especially vascular depletion. Mr. Mackenzie states, that it was most advantageously employed by Beer in 1817. Mr. Melin directs a strong astringent, consisting of a solution of four grains of lunar caustic in an ounce of distilled water, to be dropped into the eyes twice a day, in the very commencement ofthe affection, with the view of arresting its progress. Mr. Bacot (Treatise on Syphilis, 8rc. p. 136.) states, that Dr. Ridg- way originated this treatment, and that he pre- scribed ten grains of the lunar caustic to the ounce of water; he using this solution in gonor- rhoea!, as well as in catarrhal ophthalmia. Mr. Mackenzie, who appears to have had extensive experience of this practice, employs a solution of from two to four grains of this caustic in the ounce, and applies a large drop of it to the eye once a da"y; fomenting the organ thrice daily with a lukewarm collyrium consisting of one grain of corrosive sublimate and eight ounces of water. He introduces, at night, between the edges of the lids, a minute portion of an oint- ment containing a grain and a half of red pre- cipitate to the drachm. Mr. Guthrie advisesS* ointment with ten grains of the nitrate of silver (§ 49.); and Dr. Jacob a few drops of a satura- ted solution of acetate of lead or of alum, to be introduced between the lids every night and morning. 17. A green shade may be worn before the eyes; but it is not necessary to confine the patient to the house, unless the weather be cold, windy, or rainy. Exposure to a mild atmosphere is advantageous (Lawrence). 18. B. SevereInflammationofthf.Con- jUNCTivA,orPurw/ew/Ophthalmia.—Under this appellation I shall comprise those forms of con- junctivitis, whose symptoms are very violent, and whose progress is very acute; the discharge pos- sessing the purulent character. Hence they have received the appellation of blennorheea, and suppurative ophthalmia; the latter term, as Mr. Lawr ence remarks, being objectionable. Puru- lent ophthalmia generally begins in the linings of 852 EYE — Purulent Ophthalmia ok Infants. the lids. It soon extends to the conjunctiva of the globe; and, if not checked, to the cornea, which it either injures or altogether destroys. The conjunctiva is swollen and intensely red; the blood-vessels injected and enlarged; and the sur- face villous, pulpy, or granular. The discharge from the inflamed membrane is purulent and copious. Wrhen the disease extends to the cornea, interstitial deposition, causing opacity, and sub- sequently bursting, sloughing, and ulceration, if the malady proceeds, is a frequent result; pro- lapsus ofthe iris, escape ofthe humours, and col- lapse of the tunics, being ultimately produced. It is properly seated in the conjunctiva, and often goes through its course without extending deeper, unless the cornea become affected, or ulceration or sloughing takes place, as now stated. 19. a. Severe Inflammationof theCon- junctiva of Infants.—Syn. Purulent Oph- thalmia of Infants; Purulent Eye of Children, Ware; Ophthalmia Neonatorum, Auct. var.; Ophthalmia of new-born Children, Mackenzi k ; Blephar-Ophthalmitis glandulosa, Beer. —The term used by Ware is inappropriate : and that employed by Beer implies that the disease ori- ginates in the Meibomian glands, and is incorrect; these glands being merely involved in the severe inflammation attacking the whole of the mem- brane. 20. a. Causes.—Purulent ophthalmia of new- born infants has been very generally imputed chiefly to leucorrhceal discharge in the mother. Schmidt, Mackenzie, and Lawrence main- tain this opinion; and the last writer refers to cases in which the infant was affected with the disease, owing to the mother having had gonorrhoea at the time of parturition. But these are instances of gonorrhceal ophthalmia in new-born infants, which is a still more severe affection than that now being considered. I have strong reasons for concluding that the disease does not so fre- quently arise from leucorrhcea in the mother as is supposed; for, in many instances in which I have enquired into the causes, and in two or three where the intelligence of the mothers seemed de- cisive of the matter, no such disorder had ever been complained of. It should not be overlooked, as Dr. Jacob has, indeed, mentioned, that a mild form of conjunctivitis sometimes attacks very young infants from exposure to cold,— mild ca- tarrhal ophthalmia in new-born children. Of this I have seen numerous instances. But the pre- sent violent state of disease depends, perhaps, as much upon the predisposition as upon the ex- citing causes; and there can be no doubt that infants are frequently born of mothers affected by leucorrhcea, or even by gonorrhoea, at the time of parturition, without being infected by purulent ophthalmia. 21. The predisposing causes are, delicacy and susceptibility of constitution, premature birth, and whatever depresses the system. The disease is most common in twins and weakly infants; in those newly born; in those subjected to bad or foul air, to cold, and to insufficient or inappro- priate nourishment; in those deprived of the mother's care, and ofthe mother's breast; and in the children ofthe poor, and the dissolute. It is particularly prevalent and severe in Continental foundling hospitals, where the infant is without maternal care; but it is not very frequent in lying-in hospitals. LangenbecKvATcu* Chirurg. Biblioth. b. iii. p. 208.) states, that in the Lying-in- Hospital of Vienna, where the mothers are gene- rally affected with leucorrhcea and gonorrhoea, but where the infants remain with them, the dis- ease is not common; while in the foundling hospital, where the infants are half dead from cold and starvation when they are received, and deprived of their mothers, it is very prevalent. The chief causes, according to my enquiries, are those now stated, exposure to damp and cold air, improper nutriment, and especially the neglect of due ablution immediately after birth. In many ofthe cases that I have seen, the secretion cover- ing the cutaneous surface in utero, which had not been removed from the eyelids and angles of the eyes, had evidently been the chief cause; and I am convinced that the presence of this matter, owing to the changes it undergoes when allowed to remain in contact with the external surfaces, es- pecially near natural openings, after birth, is much more frequently a cause of purulent ophthalmia, than infection by leucorrhcea, although I do not deny the influence of this latter circumstance. 22. (*. Symptoms and Progress. — This affec- tion is ofthe utmost importance, as the majority of instances of blindness is caused by it. In a great proportion of cases it is far advanced before medical aid is required; it being frequently con- sidered, at its commencement, as a common cold in the eye. It generally begins three or four days after birth; but it may occur at any subsequent period; the liability to it, owing to the nature of the exciting causes, being remarkably diminished when the child is some days, or a few weeks, old. In its first stage—the Blepharo-blennorrhaa of German writers—the inflammation is chiefly con- fined to the lids; a circumstance further proving its origin in the cause now, for the first time, pointed out. The lids at first stick somewhat to- gether when the child awakes; and their edges are red, particularly at the corners. External redness of them is sometimes, also, observed. The eye is usually closed, from pain occasioned by light. The globe is in a natural state; but the linings of the lids are red and villous, espe- cially the lower, the insides of which are covered with a little white mucus. In the second stage— Ophthalmo-blennorrhaa of some writers —the in- flammation is more severe, and extends to the conjunctiva of the globe. Redness and tume- faction are increased; the lids are swollen and red even externally; and the discharge becomes copious and purulent, agglutinates the edges of the palpebral, accumulates beneath them, and bursts out between them, and pours over the face. The whole of the conjunctiva is now minutely injected, of a uniform bright scarlet colour, and tumefied; its surface is villous; and its loose folds between the lid and the globe be come enlarged, form tumid rolls, and are finely granulated. These folds often evert the tarsi, causing ectropium, which generally subsides with the disappearance of the disease. When the swelling of the lids is great, the upper usually overhangs the lower, and is externally of a bright red. These appearances are aggravated by crying, when the globe is pushed forwards. The discharge is yellowish in various tints; and, in unhealthy or jaundiced children, it is often yel- lowish green. It is sometimes whitish; and it ia EYE — Purulent Ophthalmia of Infants. 853 then less abundant and thicker. It is more rarely ichorous orsinious; but it is then thin and ex- coriating. An admixture of blood in the dis- charge is also rare. 23. Both eyes are usually affected; but the complaint commences generally a few days earlier in one than in the other. The attendant consti- tutional disturbance is very considerable; the tongue being white and loaded, and the bowels disordered. The infant is restless, feeble, and ultimately, especially if an unfavourable issue has taken place, pale, emaciated, and cachectic. When the disease extends to the conjunctiva of the globe, its duration, until either of its bad effects supervene, is various, but commonly from seven to fourteen days. It, however, is some- times confined, for a considerable time, to the conjunctiva ofthe lids in a slight or chronic form, before the globe is affected. 24. )•. Terminations.— In the course of the disease, it is important that the practitioner should examine the eye so as not to increase the disorder. If the infant be asleep, the tarsus of the upper lid should be pushed very gently and lightly, up- wards and backwards; but no further than to obtain a clear view of the cornea. If it be awake, the lids should be separated quickly, whilst it is quiet, and before the muscles can resist. An attempt to see the eye when it is crying is either ineffectual or injurious.— 1st. In the less severe cases, and in the more violent attacks, if early and judiciously treated, the tumefaction of the conjunctiva subsides gradually; the discharge is lessened, and becomes whitish; and the mem- brane gradually resumes its healthy state.— 2nd. Opacity of the cornea may supervene, partially, or generally; and, from interstitial infiltration of lymph, either into the tissue of the corneal con- junctiva, cause a superficial bluish film, or into the laminas of the cornea, produce dense and total opacity.— 3d. Adhesion of the iris to the opaque cornea may occur, especially when the inflammation has extended throughout the latter, and passed to the iris.— 4th. Infiltration of pus between the lamella? of the coruea, or onyx, causing ulceration of the external lamellae, may take place. The ulceration may be of various extent and depth,— may affect nearly the whole surface of the cornea, or penetrate it, causing prolapse of the iris. This latter may adhere to the ulcerated part, and the ulceration either cease, or extend to the interior ofthe eye.—5th. Slough- ing of the cornea, which has been described by Saunders and Lawrence, but doubted by Mackenzie, may supervene, partially or gene- rally. The part becomes dusky, loses its polish and vital cohesion, and assumes a dirty greyish or brownish appearance. A line of separation after- wards forms at the margin, and the dead part is thrown oft'. The whole cornea may perish thus, and the iris protrude through the aperture, pre- senting an irregular brownish or dirty promi- nence; and being either covered by the mem- brane ofthe aqueous humour, or nakedly exposed, the humours having escaped. Partial sloughing generally leaves a ragged ulcer, which often ex- tends into the anterior chamber, causing prolapse of the iris. These terminations often quickly su- pervene and rapidly proceed, in young, feeble, and ill-nourished children, until the humours es- cape and the eye is destroyed. 23. When the entire cornea has either sloughed or ulcerated, and the humours have not escaped, the projecting iris recedes, and becomes covered by an opaque pellicle, the front of the eye being flattened. After partial ulceration or sloughing, the iris either adheres to the internal surface of the cornea, or prolapses through the opening; the projecting part gradually subsiding and disappear- ing, leaving a cicatrix in the cornea. In this case, the iris also adheres to the cornea, and there is change of figure, with contraction of the pupil; vision being either impaired or lost, according to the extent of the change. When ulcers of the cornea are spreading, they are of a dusky or yel- lowish white, irregular in their surface, and often with a ragged edge; but when they begin to heal, they have a greyish or bluish aspect; be- come smooth, soft, and gelatinous, from deposition ofthe matter which is to repair the breach; and red vessels pass from the conjunctiva, through the intervening transparent portion of the cornea. They thus heal, leaving a permanent opaque cicatrix (Lawrence). 26. d. Prognosis.— Although remarkably vio- lent, this affection readily yields, if treated early, and before the cornea has sustained any in- jury. The appearance of the discharge often indicates the state of tlxp disease. The whiter and smaller in quantity, the lower is the grade of inflammation. The yellower and more co- pious the discharge, the more acute the dis- order. An admixture of blood in it, indicates a violent state of action; but is not, in itself, dangerous. A thin, ichorous, or sanious dis- charge, marks the existence of sloughing or destructive ulceration. If there be superficial ulceration without onyx, probably only a slight speck may remain. If the ulceration be deep, permanent opacity will be the result. If the iris protrude, the pupil will be disfigured, and vision more or less impaired. If there be considerable onyx, the matter may be absorbed, or the puru- lent infiltration may increase, the cornea burst, and the eye become partially or totally staphylo- matous. 27. f. Treatment.— In the most acute cases, when the conjunctiva oculi is bright red and swollen, especially if the cornea looks hazy, or the palpebrae bright red and tumefied, depletion by leeches is requisite. A leech may be placed upon the temple, or, as Mr. Lawrence advises, upon the middle ofthe swollen upper lid; and it will generally procure a sufficient evacuation. If both eyes are affected, one may be applied to each temple or superior palpebra; but in weak infants, the two leeches should be small. If the state of the cornea be doubtful, and vascular action in the conjunctiva still acute, although ihe lids be not much swollen, nor very red, it will be better to apply the leech. Dr. Mon- teath (Trans. o/Weller, &c. vol. i. p. 61.) advises scarification of the inner fleshy and gra- nular surface of the lids, in preference to the application of leeches, the lids being kept everted until a sufficient quantity of blood has flowed, the replacement of them being always followed by arrest of the bleeding. Mr. Mackenzie di- rects the immediate application of astringents ; but in the more violent cases, before the cornea has been materially injured, the depletion is be- neficial. In the less severe attacks, and in feeble 84 854 EYE — Purulent Ophthalmia in Adults. or ill-nourished infants, the astringents about to be noticed may be at once employed. In every instance, purgatives ought to be prescribed. One grain of hydrargyrum cum creta, or of calomel, may be given, with three or four of magnesia or of rhubarb, at bedtime, and a dose of castor oil in the morning. A small blister may be applied on the posterior and middle part of the scalp, as advised by Dr. Monteath ; but it should be removed in five or six hours, and the part care- fully attended to. The eye should be bathed frequently with tepid milk and water, and a little fresh butter, or a mild form of the red precipitate ointment, applied between the edges of the lids at night, to prevent their agglutination, and favour the escape of the discharge. 28. Astringent collyria are more efficacious, and safer in this affection, than in any other, especially when resorted to at its commencement. But in severe cases, when the inflammation has proceeded so far as to endanger the cornea, it will be much safer to premise depletion, than to enter at once upon the use of astringents. Mr. Wake recommends a preparation formed by pouring eight ounces of boiling water on eight grains each of sulphate of copper and Armenian bole, and two of camphor. Sc hmidt prescribes a lotion of two grains of sulphate of zinc, three drops of liquor plumbi super-acetatis, twelve drops of spiritus vini camphoratus, and an ounce of dis- tilled water. Mr. Guthrie directs the nitrate of silver ointment (§ 49.) to be applied with a brush over the inside of the lids. Mr. Mackenzie employs a collyrium of one grain of corrosive sub- limate and eight ounces of water, three or four times in the day ; and, having washed off the dis- charge by this lotion, he applies, once, or at most twice, a day, to the conjunctiva, a solution of four grains of lunar caustic, or of six grains of sulphate of copper, in an ounce of water, by means of a camel-hair pencil ; preventing the agglutination ofthe lids by smearing their edges at night with the mild red precipitate ointment (consisting of from twelve to twenty grains ofthe precipitate to the ounce). Dr. Monteath uses a nearly similar collyrium to that prescribed by this writer. Mr. Lawrence advises a solution of from two to ten grains of alum in an ounce of water, to be carefully injected between the lids three or four times in the twenty-four hours, so as to wash out the purulent secretion; and after- wards a soft rag, moistened in the solution, to be laid over the eye for a short time; the bowels being regulated by a mild aperient If there be occasion to change the astringent, he prefers the lunar caustic solution, gradually increasing its strength from two grains to the ounce, to four or six, to be dropped between the lids twice or thrice a day. 29. When the cornea has ulcerated or sloughed, the infant is generally pale, weak, irritable, and restless ; and tonics are required. The sulphate of quinine in the form of syrup, and the resinous extract of bark blended in milk, and given every three, four, or six hours, are the best preparations. The solution of the nitrate of silver, or of alum, may be applied to the eye. Opacity of the cornea is generally permanent; but instances of recovery have occurred. M. Billard mentions a case in which the recovery was spontaneous. 30. l. Purulent Ophthalmia in Children.—The treatment just recommended is most appropriate to newly-born infants, or to children of one, two, or three years old. In these latter, and in those somewhat older, the local depletion should be more active, according to their habit of body and strength ; and blisters behind the ears are of much service. Blisters, unless employed with caution, and only so far as to produce slight red- ness, and followed by the application of warm poultices to the part, often are productive of much trouble in young infants ; in older subjects, they are more beneficial. In the latter class of patients, vascular depletion, according to the cir- cumstances of the case and of the patient, purg- atives, blisters, and astringent applications, con- stitute the chief means of cure. Purulent oph- thalmia introduced in large or crowded schools or foundling hospitals, may spread extensively and prevail long. Mr. Macgregor has described its prevalence for some years among the children of the Military Asylum at Chelsea. It was most severe in those having red hair, or of the scrofulous diathesis. It commenced in the eye- lids with itching, sticking together of the lids on waking in the morning, followed, in twenty- four or thirty-six hours, by a viscid mucous secre- tion, extension of the inflammation of the con- junctiva oculi, redness of the skin around the eye, and a purulent discharge. General bleeding, leeching, purgatives, blisters behind the ears and on the nape of the neck, cold lotions, low diet, and, subsequently, astringent collyria, and the unguentum hydrarg. nitratis, at first mixed with twice its quantity of lard, but afterwards of its full strength, applied to the lids by means of a camel-hair pencil, "were the remedies found most beneficial. 6. Purulent Ophthalmia in Adults.—Syn. Oph. purulenta or puriformis, Suppurative Oph., Egyptian Oph., ophthalmo and Blepharo- blennorrhaa, Auct. var. ; Oph. contagiosa; Oph. catarrhalis bellica ; Blepharotis glandu- laris contagiosa, Beer; Adenitis palpebra- rum contagiosa; Epidemic contagious Oph., Rosas; Conjunctivitispuro-mucosa contagiosa vel Egyptiaca, Mackenzie; Purulent Oph. in the Adult, Lawrence. 31. This affection is essentially the same as that just described, as to both nature and seat ; it commences and extends in a similar manner, and produces the same ill effects, especially as respects the cornea and iris. Its severity, its serious consequences, its contagious properties, and its extensive prevalence at the commence- ment of tins century, impart to it the highest interest. Assalini states, that two thirds ofthe French army in Egypt were affected with the complaint. Dr. Vetch treated 636 cases, in- cluding relapses, belonging to the second batta- lion of the 52d regiment, from August 1805, to August 1806 ; fifty having lost both eyes, and forty, one eye : and the ophthalmia depot, under his able care, contained, in the summer of 1808, upwards of 900 cases. Mr. Macgregor men- tions that, the returns of Chelsea and Kilmain- ham hospitals furnished 2317 cases ; soldiers who had lost the sight of one eye not being in- cluded in the number : and that, from April to December, 1804, nearly 400 cases of this dis- ease occurred in the Royal Military Asylum ; and from that time to the end of 1820, upwards EYE — Purulent Ophthalmia in Adults. g55 of 900 cases additional, exclusive of relapses, had taken place in the same establishment. About this time it appeared in a large boy's school in Yorkshire; blindness, or serious injury to sicht, having resulted in nearly twenty instances.— Mueller treated 1604 cases, including 200 relapses, in the Prussian garrison of Mentz, during three years and a half: 1344 were re- stored to the service ; fifteen became blind in both eyes; eighteen had vision impaired in both; and twenty-six were blind of one eye,—furnish- ing the most successful results upon record; but the complaint was more mild than in the British troops. 32. a. Causes.—The much discussed question as to the propagation of the disease by contagion* has been fully and ably considered by Edmond- ston, Vetch, Macgregor, Graeffe, Mu- eller, Omodei, Rust, Lawrence, and Mackenzie; and completely set at rest by the evidence they have adduced. My limits will permit only a brief view of the matter. It has been contended — 1st. That the complaint is pro- duced by atmospheric and other causes, and that it is not contagious; — 2d. That, although it arises from these causes, it is contagious; — and, 3d. That it is a specific disease, communicable by contact of the purulent discharge, and not arising sporadically from other causes. — One of these opinions must be true; and, if true in all respects, the others must be false. In order to arrive at a correct conclusion, I shall first briefly review the facts adduced in support of the non-contagious nature of the complaint; next, notice those prov- ing its contagious properties; and, lastly, show in what manner and under what circumstances it manifests these properties. 33. 1st. Those who contend that this disease is not contagious, argue that, in Egypt, the * It may be supposed from the lines in OVID, " Dum spectant laesos oculi, Isduntur et ipsi, Multaque corporibus transitione nocent." and the remark in Plutarch (L. v. Symp. 7.) as to " the readiness and certainty with which the contagion of ophthal- mia spreids amongst persons living together, that the conta- gious nature of the disease was well Icnown to the ancients. Galen (De Differ. Febr. i. c. 2.) enumerates it amongst in- fectious maladies ; and Rabbi Moyses (Aphor. 24.) avers, that whoever attentively regards inflamed eyes, will contract the complaint. BENED1CTUS Faventinvjs (Prax. v. i. sect. ii. c. 2.) gives it as his opinion, that a morbid effluvium proceeds from the eyes in ophthalmia, which, through the medium of the atmosphere, will affect those that are near. The same opinion is stated by MERCUHIALIS (Prax. lib. i. cap. 38.). DlEMERBROECK (Observat. 55.) mentions the case of a lady who was attacked by the complaint, and two or three days afterwards three of her servants were also seiz- ed. He arrested the disorder by the following collyrium : — U- Zinci Sulphatis £j.; Sacchari Candi 5 j.; Aquae Plantaginis J ij. ; Aq. Kosaruin J j. M. Similar facts an-l opinions are to be found in the writings of RlEDLIN (Curat. Med. Millen. Observ. 187.), Wedel"(De Ophthal. Jena;, 1684.), and Boerhaave (De Morbis Ner- vorum, ii. p. 512.). Dr. Edmondston has adduced a very striking fact, about to be referred to, from the thesis of a Dr. Armstrong. From this it will appear, that although the contagious nature of the disease was not fully shown, nor generally believed in, until it was demonstrated by Dr. Ed- mondston, yet it did not altogether escape the notice of writers ; some of whom, as DlEMERBROECK, were at a loss to account for the facts they observed ; or to explain how a virus could be conveyed, through the medium of the air, from the eyes of the diseased to those of mere spectators. The vulgar belief, however, in its contagious nature, has long subsisted in various countries; but the vulgar judge by results and assemblages of facts, without caring for the expla- nation, or disbelieving them because they are unable to ac- count for them ; and they often judge aright. country in which it is endemic, and whence it was brought by the European armies invading it at the termination of the last and the com- mencement of the present century, it was not considered contagious; that this property was not noticed by any of the ancient visiters of that country, or by any who travelled thither before the period now mentioned; and that the army . physicians and surgeons, who treated the ma- lady there, did not suppose it to be contagious. Assalini, a physician who accompanied the French army into Egypt, denies this property, and refers it to the causes of ophthalmic diseases existing in that country; especially the powerful light and glare from the sandy surface, the dust floating in the air, the night chills and dews following the burning heat of day, and other atmospheric vicissitudes, to which the troops in very active service were necessarily subjected. Hence he, and other army physicians, viewed it as a very acute catarrhal inflammation, affecting those chiefly who were most exposed to these causes. Those who espouse this opinion, further appeal to the alleged fact, that there was no dis- semination of it in the families, or districts, to which soldiers or other persons affected by it returned. But this argument is, in my opinion, more specious than correct; for instances were not numerous of soldiers having been dispersed in civil communities with the disease in its early and active stages ; and where such occurrences did actually take place, many of the circumstan- ces favouring contagion thereby ceased to exist. But, besides, the results were not altogether such as the non-contagionists have asserted, as excep- tions now and then occurred to this broad and incautious statement. The fact noticed by Wal- ther, that the complaint seemed to lose its con- tagious properties when single patients lived in their families, under the ordinary domestic rela- tions, is admitted by him to be weakened by one exception; and is open to the objection just offered. The experiments of Mueller, who attempted to transmit the disease by applying the matter to the eyes of dogs, cats, and birds, with- out infecting them, are contradicted by others which succeeded. The experiment of Mr. Mac- kesf.y (Edin. Med. and Surg. Journ. vol. xii. p. 411.), Who applied the discharge to his own eyes without communicating the malady, only shows that what is known and allowed of other contagious affections also obtains in this, viz. that the state of health, and of the organ of the ex- posed person, as well as the state of weather, frequently both dispose to, and prevent, the com- munication of a contagious disease; and that even inoculation will sometimes fail to convey it, owing to these and other circumstances. 34. 2d. Numerous facts have been adduced in proof of the contagious nature of the disease, to which only the most cavilling scepticism can object. Mr. Macgregor met with three in- stances of nurses, in the Military Asylum, having been infected by the accidental introduction of the matter into their eyes whilst injecting the eyes of patients; the affection manifesting itself within twelve hours afterwards in all the cases. Dr. Vetch applied the morbid secretion to the eye of a dog, in which it soon produced great irritation ; but the animal was lost before the result could be ascertained fully. Rim a, Va- 856 EYE — Purulent Ophthalmia in Adults. sam, Graf.ffe, and others, produced the dis- ease repeatedly in dogs and cats by the application of matter to their eyes; and M. Guili.ie intro- duced under the eyelids of four blind children the purulent discharge, and the disease was commu- nicated in each instance. 35. But independently of these incontrovertible facts, others equally satisfactory may be adduced. It is not denied that the disease extended from the detachments of the French and English armies which returned from Egypt, to the troops in Italy, Sicily, Malta, Gibraltar, France, and England, which had direct communication with them; the progress of the complaint having been clearly traced from the infected detachments to the fresh troops. The excellent accounts furnished by Dr. Edmondston, Vetch, .Mvcgregor, Rust, Walther, Mueller, Graeffe, and others, completely demonstrate its spread by contagion, and show that it extends rapidly among soldiers crowded in barracks, using the same utensils and linen, whilst the officers, who live separately, are seldom attacked. Rust states that, in Mentz, which was garrisoned by Prussians and Austrians, it spread extensively among the former; while the latter, who inhabited separate barracks, in a dif- ferent quarter ofthe town, entirely escaped. Dr. Edmondston adduces a most conclusive fact. In 1782, the Albemarle ship of war took on board, in the West Indies, three sailors, with inflamed eyes, from a slave-ship, in which the disease pre- vailed. On the fourth day after their reception, the disorder appeared in the Albemarle; and, by the seventh morning, twenty-two men were unfit for duty. Those affected were now separated from the healthy, and the progress of the malady was arrested, and, in the course of a few weeks, entirely ceased. Similar facts to the above may be adduced: and most of those about to be no- ticed in illustration of points connected with this subject, fully prove contagion. Numerous in-' stances have occurred in civil life, of the. disease extending from one, to all the members of a fam- ily; and, in the public service, where the circum- stances favouring its spread are more numerous and influential than elsewhere, it has been arrest- ed by separating the diseased from the healthy, and confining each person to his own utensils, cloths, and sponges. Mr. Macgregor states that, when the complaint was spreading rapidly in the spring of 1810, among the children of the Military Asylum, those affected were removed into a detached building, so as to cut off the com- munication between the healthy and diseased ; and that it afterwards declined. That it did not arise from the state of the air, or any other general cause, is shown by the circumstance of its prevalence among the boys for nearly a month, before the girls were attacked; and by the fact, that all the adults who did not mix with the sick escaped, while those who were connected with them all suffered, the assistant surgeon excepted. Similar proofs are adduced by Rust, Walth- er, and Owouei, in the works referred to in the Bibliography. Mr. Macgregor has given a most convincing account of its extension, by contagion, from two boys, brothers, in the Mil- itary Asylum, in his Memoir referred to here- after. 36. 3d. The origin of the contagious property, and the manner of, and the drcumstances favour- ing, its propagation, are matters of great practi- cal importance, as respects both prophylactic and curative measures. — (a) As to the origin of the contagion, Dr. Vetch has made an important observation, and one which appears to approach very nearly to the truth. 1 le remarks that, from whatever cause inflammation of the conjunctiva may originate, when the action is of such a na- ture or degree as to produce a purulent discharge (Ophthalmo-Blennorrhea), the discharge so pro- duced operates as an animal virus when applied to the conjunctiva of a healthy eye. To this I would merely add, of a predisposed or susceptible person.—The opinion of Mr. .VlACKENZiEagrees with that now stated. He observes, that it scarcely admits of a doubt, that the discharge in catarrhal ophthalmia, especially when distinctly puriform, if conveyed by a towel, or by the fingers, to the eyes of other persons, will excite a conjunctivitis still more severe, more distinctly puriform, and more dangerous in its effects, than was the origi- nal affection. He has arrived at this conclusion, from having observed many instances, in which the disease had arisen in one of a family from atmospheric exposure, and several others had be- come affected, it having been, in the first attack- ed, comparatively moderate, but, in the rest, much more violent and puriform. Similar facts have been remarked by myself. That the disease may arise spontaneously, and afterwards extend by con- tagion, is evinced by the following occurrence ad- duced by M. Guillie. A French slave-ship left the coast of Africa in .1819, with 160 slaves crowded in the hold. No case of ophthalmia existed among them, nor among the crew, when they put to sea. But fifteen days afterwards it broke out in the negroes, and spread rapidly among them, and subsequently among the crew, twenty-two in number, one only of whom escaped. On their passage across the Atlantic to the West Indies, they met another slave- ship, the crew of which was similarly circum- stanced to themselves. Nearly one half of the crew and slaves lost their sight in one or both eyes. 37. (b) As to the manner of the propagation of the disease, some difference of opinion is en- tertained. Dr. Vetch believes that it is not communicable by a contagious miasm conveyed through the medium of the atmosphere ; and thinks that direct application of matter is neces- sary to infection. Mr. Macgregor expresses a similar opinion, although many of his facts favour the conclusion at which I shall arrive in the se- quel. Mueller, on the other hand, considers that the contagion is generally conveyed by the air, although it necessarily also admits of being propagated by direct contact; and, in proof of this position, adduces the fact of the medical at- tendants and nurses, notwithstanding their care to avoid the contact of the discharge, having been frequently affected. Walther entertains the same opinion, and appeals to similar facts in support of it. Dr. Edmondston, the first writer who demonstrated the contagious nature of the complaint, and attempted to assign the range and laws of this property in respect of it, considers that it is contagious, not only by the contact of the discharge, but also by fomites, and through the medium of the atmosphere within a limited range, when a number of cases are brought EYE — Purulent Ophthalmia in Adults. 857 together, in close apartments or crowded hos- pitals. Such appears to be the opinion of this able physician, promulgated as early as 1802; and, although not always candidly objected to at the time, and for some years afterwards, it is now confirmed in every respect by the more recent experience of the best writers on the dis- ease in this country and on the Continent. 38. (c) The circumstances favouring the dif- fusion of this contagion are in no respects differ- ent from those which promote the spread of other contagions :— 1st. Novelty of morbid impression, or the unblunted sensibility and unimpaired susceptibility of those who are exposed to the infectious miasm for the first time; as a per- son coming out of a pure air into a foul atmo- sphere or close apartment, or breathing an efflu- vium to which he has heretofore been a stranger, is much more sensible of its operation, and much more affected by it, than one who has gradually become accustomed to it by frequent or con- tinned exposure.—2d. Whatever increases the discharge, or accumulates or concentrates the emanations from it, and from the diseased organ; as want of ventilation, crowding together of the sick, want of cleanliness, &c. ; will greatly in-, crease the contamination of the air more imme- diately surrounding the patient, and favour the - infection of the healthy who are most susceptible, when they approach within a certain limited j range.—3d. Whatever multiplies the chances of conveying the morbid secretion directly to the eyes of the sound; as sleeping in the same bed or apartment, using the same towels, sponges, and utensils, and the want of domestic cleanliness; will augment the number of cases.— 4th. What- ever depresses the vital powers; as unwholesome diet, insufficient clothing, intoxication, exposure to cold, &c, fatigue, malaria, a confined or foul air, the depressing passions, and venereal excesses; will render persons more susceptible of infection.—And, 5th. Exposure to the more com- mon causes of ophthalmia about the same time as to contagion, or shortly before or after it, will likewise assist or determine its influence.—It is hardly requisite to appeal to facts in support of these positions. The numerous works referred to furnish them in abundance, especially those of Edmondston, Macgregor, and Vetch. Mr. Macgregor found that the complaint was much more severe and of longer duration in hot and moist, than in cold, weather; and Dr. Vetch ascertained that a humid atmosphere and marshy soil increased both its violence and spread. 39. From the above, it may be inferred— 1st, that the disease may be produced by common causes, and without the operation of contagion;— 2dly, that, when so excited, and existing to such a degree as to give rise to a puriform discharge, it is capable of propagating itself, under favour- able or particular circumstances;—3dly, that it spreads, not onlv by contact, but also through the medium of the atmosphere, within narrow limits; more especially when numbers affected by it are crowded together, and the air is humid or impure, and those exposed to the contagion are predisposed by the operation of the causes mentioned above (§ 4.). Hence its remarkable virulency in ships, particularly transports, slave- ships, barracks, prisons, workhouses, and schools; and it therefore should be referred to the second 72* category, stated at the commencement of the enquiry (§ 32.). 40. 1. Symptoms and Progress.—The symptoms succeed each other with different degrees of ra- pidity and severity, even in persons suffering from the same infection, and in the same place, owing to the previous health, the habits, and constitu- tion of the patients. The disease is more mild in females than in males; and it is more violent about the period of puberty than at an earlier or later age. It has also been more severe in one place, or regiment, than in another; and it was evidently more violent among the British troops, than among the French, Germans, or Italians, owing most probably to the more phlogistic diathesis and robust constitutions ofthe former than of the latter, and to their fuller living and greater in- temperance. 41. (a) The more acute and violent states.— In its first stage, the complaint is confined to the palpebral conjunctiva; and is attended by stiff- ness of the lids, itching or watering of the eye, a sense of sand or some foreign body below the lids, succeeded by sticking of them together, on wakening from sleep, and greater fulness of them externally than usual.— It is seldom seen by the physician at this period; or until it has advanced to the conjunctiva oculi, or its second stage. This membrane then rapidly becomes bright red, remarkably vascular, and greatly swollen; the chemosis being sometimes such as to conceal the cornea. Patches of ecchymosis are also seen, and the whole palpebra are much tumefied, and oc- casionally also red externally. The discharge is profuse and purulent, often in a few hours from the commencement, but always soon after the inflammation has extended to the globe; and sometimes it is so copious as to pour over the face and clothes; but there is no secretion of pus in the chambers. In this stage, the pain becomes severe, seated deep in the eye, and attended by a sense of a foreign body in the eye, of fulness or great distension, with throbbing in the temples, and headache. These symptoms, especially the pain, often remit, or occur in paroxysms, or return after having been removed for a time. The con- stitutional disturbance is not severe; the pulse, tongue, and appetite, not being materially affect- ed. The cornea is liable to the same effects as have been described above (§ 24, 25.) ; but the swelling of the lids, and the tumefaction and overlapping of the conjunctiva, and the accumu- lation of pus over the cornea, or in the depression of which it forms the bottom, frequently prevent its state from being ascertained.—In the third stage, the symptoms gradually subside; the swelling, pain, and discharge are diminished; the external tumefaction is lessened; and the lids, which before were somewhat inverted, from the cartilages not yielding, are now slightly everted, especially the lower. As the discharge dimin- ishes, it gradually loses its purulent characters, and becomes thinner, more mucous, or gleety. The internal surface of the eyelids, the semilunar membrane, and caruncula lachrymalis, which were the first parts affected, are the last from which the disease disappears. The right eye is more frequently, and generally more severely, at- tacked than the left; and its sight oftener lost. In some cases, only one eye is affected; but commonly both are seized, although an interval 858 EYE — Purulent Ophthalmia in Adults. of several days occur before the second becomes inflamed. Such are the features of this disease as it prevailed in the British army, and as it sometimes occurs in civil life under certain circumstances. 42. (b) The milder or chronic states.—These were most common on the Continent, both in the army and in civil society. Mr. Macgregor, Dr. Vetch, Professor Walther, and Dr. Mu- eller, particularly the last, have pointed out, not only the origin of the complaint, in the con- junctiva of the lids, but also its long persistence in this part, in some cases, and its entire limit- ation to it, in others. In all the grades, the inflammation both begins and terminates in it. — In the slightest grades, the patient complains of pressure or uneasiness, with a sense of dust or sand, in the eye; but without redness of the globe, or of the external surface of the palpebral. The conjunctiva tarsi is villous and dark red; but towards the globe it is smooth, and its vessels distended. The eyeball has an irritated appear- ance : there are an increased flow of tears, and a mucous secretion, but little or no pain. The disease may continue long in this mild form, or may yield to treatment in two or three weeks ; or it may pass into a higher or severer grade.— The second or intermediate degree may be an aggravation of the first or slightest grade, or may commence with all its characteristic features. The conjunctiva of the lids has a granular appear- ance, which becomes more conspicuous when the inflammatory tension is abated, and is swollen, dark red, and covered by a puriform secretion. The lids are tumefied; the pain is considerable, and as if caused by a foreign body. This form may continue for weeks or even months, and pass into the severe or acute state already described (§ 41.), owing to atmospheric changes or other causes; unfavourable consequences to the organ supervening sometimes in twenty-four or thirty- six hours. 43. (c) The alterations which the conjunctiva undergoes are of much importance. In the mildest grade, the membrane appears as if covered with dust, or velvety; in the severest degrees, it seems strewed with rough bodies, or with granulations, resembling those of a healing wound. These bodies exist in great number, arise by a broad basis, and have a round prominence at first, which becomes flattened or angular, by pressure against the globe. The largest of them are in the middle of the lid, the smallest at the edge and near the angles. They are sometimes crowded very close, and are most remarkable in the upper lid. Their colour varies from the darkest blood red to the palest brick hue. Mu eller considers this change of structure not as a mere effect of inflammation, but as proper to the disease, and as connected with the production of the contagious secretion disseminating the complaint. 44. y. Consequences.— 1. Suppuration of the Cornea, and destruction by ulceration, sometimes supervene; the progress of the disease usually leading to the escape of the humours, and collapse of the globe.—2. Ulceration frequently takes place, to the extent, and in the manner, described above (§ 24, 25.).—3. Sloughing of the cornea rarely or never occurs in this variety. Mr. Law- re nce has not met with it, and other writers do not mention it.—4. Bursting of the cornea is le*> rare, particularly during suppuration or ulceration. Dr. Vetch met with cases, in which the rupture occurred without previous change; the aqueous humour having escaped by a clear division or rent in the cornea, which afterwards became opaque, and projected around the open- ing; but this occurrence is very seldom observ- ed.—5. Interstitial deposition in the conjunctival covering, or the corneal lamina?, occasioning opacity of every degree; the slighter grades often disappearing after recovery.—6. Loosening or thickening of the mucous membrane covering the cornea, with enlargement of its vessels, and dimi- nution of its transparency.— 7. Opadty from cicatrisation of ulcers.— 8. Prolapse of the iris, partial or total (Staphyloma racemosum). — 9. Adhenon of the iris to the cornea (Synechia an- terior), either with or without prolapse. —10. Staphyloma, general or partial, or other changes, from extension of the inflammation to internal parts of the organ.—11. Weakness or irritability of the eyes, which usually disappears sooner or later.— 12. Impaired vision (Amblyopia), arising from numerous causes; as turgidity of vessels in the orbit, and surrounding the optic nerves; slight alterations of the choroid, retina, or lens; and lesions within the cranium.—13. Thickening, induration, and granulation of the conjunctiva of the lids.—14. Temporary and permanent ectropi- um and entropium.— And, 15. A great tendency to relapse, upon exposure to very slight causes. This last especially occurs, when the palpebral conjunctiva has not been restored to its natural state, — a result not readily attained after severe or prolonged attacks, and which Walther doubts ever to be entirely accomplished. Hence a person may be considered as cured, but expe- rience a return of the complaint, from exposure to cold or intoxication, and may spread the disease in the family in which he resides. 45. o. Diagnosis.— Purulent ophthalmia in the adult may be mistaken for the catarrhal and gonorrhceal varieties. The peculiar change in the palpebral conjunctiva, the great chemosis and swelling of the lids, the extreme redness and vas- cular congestion, the profuse purulent discharge, the long continuance of the complaint, its ten- dency to affect the cornea, and the disposition to relapses, sufficiently distinguish it from catarrhal or mild ophthalmia. Nevertheless, the mildest cases of the former, and the severest of the latter, hardly differ in any respect. The specific cause and nature of gonorrheal ophthalmia, and its uniformly acute and violent form, distinguish it from the purulent variety. There are, besides, other differences, which will be noticed here- after (§ 59.). 46. t. Treatment.—(a) Of the most acute, or highest grade of the disease.—The intention should be to arrest the violence of the inflam- mation, and prevent the extension of it to the cornea. If the patient be seen sufficiently early, or before the conjunctiva oculi be much inflamed, or chemosis have appeared, the treatment advised in catarrhal ophthalmia will generally succeed. But, if the disease be thus far advanced, and ha. assumed a severe form, the most active anti phlogistic means ought to be resorted to. Vetch, Mueller,Rust, Walther,Lawrence, and other experienced writers, recommend venasection carried at once sufficiently far to produce a de- cided effect upon the circulation, without regard EYE—Purulent Ophthalmia in Adults. 859 to the quantity abstracted. Drs. Edmondston, Mackenzie, and Jacob place much less reliance upon large general bloodlettings, which have but little effect upon the local inflammation. This opinion coincides with the result of my own limited experience. Dr. Jacob has seen the ab- straction of blood carried to the utmost extent; " he has seen repeated bleedings of forty, fifty, and even sixty ounces, and streams flowing from the arm and temporal artery at the same time, without generally beneficial results." After one full bloodletting, these writers coincide in trust- ing chiefly to local depletions, by cupping in the temples, by the application of from twenty to thirty leeches over the cheek-bone and temple, and by scarifications of the inflamed conjunctiva. This last is advised chiefly by Dr. Edmondston and Mr. Mackenzie; but it is objected to by Mr. Lawrence, on the grounds that the wounds thus inflicted increase the local irritation; in the most severe cases, however, the advantage accru- ing from the practice far outweighs any incon- venience contingent on it. Mr. Mackenzie places scarification of the conjunctiva among the most effectual means of combating the conta- f'ous ophthalmia; but makes no mention of Dr. dmondston, who, many years before, strongly insisted on this practice. When the chemosis is great, Scarpa and Walther recommend a por- i tion ofthe conjunctiva to be cut out, either from the eyelid or the globe; several drachms of blood usually flowing from the incision, with great relief to the symptoms. When the tume- faction is such as to project the membrane be- tween the lids, or to overlap the cornea, Dr. Jacob directs an extracting knife to be run from I one end of the tumour to the other, the effused serum and much blood generally escaping by this means. 47. Having practised bloodletting so as .to j make an impression on the circulation, conform- ably with the principles espoused in other places (see Blood, § 64, 65.), and immediately afterwards applied leeches, or scarified the con- junctiva, according to circumstances, full doses of calomel, antimony, or James's powder, and opium, conjoined, should be immediately taken, and followed, in a few hours, by a brisk purgative, and this latter, by a cathartic enema. If the calomel, antimony, and opium have been exhi- bited for the first time in the morning, they may be given again at bedtime, if the case be very acute; the cathartic being repeated at an early hour in the morning. If the tongue be loaded, or the stomach disordered, an antimonial emetic should follow the bloodletting, and precede the medicines now directed, which should be given soon after the full operation of the emetic, and repeated according to their effects. Having thus acted upon the circulation and the prima via, without materially diminishing the local action and pain, diaphoretics and nauseants may be resorted to. Full doses of Dover's powder, or antimony conjoined with opium, promoting their operation by diluents and pediluvia, will gene- rally be of much service. Nausea kept up by these medicines is sometimes of use, in the more severe or obstinate cases, before the cornea is affected; but under other circumstances, it is seldom beneficial The same remark is appli- cable to mercury exhibited with the intention of affecting the system. The most efficient and certain derivative cathartics, in this disease, are equal quantities of castor oil and spirits of tur- pentine, the same being exhibited in enemata (F. 151.) ; but they should not supersede the other means. The antiphlogistic treatment ought to be strictly enforced in an early stage of the disease, particularly in robust, phlogistic, and well-fed persons. In the dark-skinned races, as well as in persons of relaxed or cachectic habits, bloodletting is injurious; and even local deple- tions should be cautiously prescribed. 48. The local Treatment is even more import- ant than the constitutional. After local bleed- ings, the frequent application of cloths moistened with cold water, or viuegar and water, and, when the headache is urgent, or the chemosis great, the cold effusion on the head, repeated twice or thrice daily, are favourably mentioned by Walther, Vetch, Gericke, and Lawrence. If the cold applications cannot be borne, or if there be spasm ofthe lids, warm fomentations may be used for a short time; but they should not be long persisted in, or too frequently repeated, unless they be alternated with astringents. Tepid ablu- tion is, however, both serviceable and requisite. Cold or warm applications should, therefore, be employed according to circumstances. Mr. Tra- vers prefers those that are tepid, in the painfully acute stage. Whichever be adopted, ought to be carefully attended to by the practitioner himself As soon as the conjunctiva becomes somewhat paler, or appears flabby, astringent applications ought no longer $o be withheld. In relaxed habits they should be very early applied, or im- mediately follow the local depletion. Mr. Me- lin and Dr. O'Halloran, from having been dissatisfied with the antiphlogistic treatment, were led to the use of powerful astringents, not only in the first stage, but also when the purulent discharge and chemosis were fully established. Dr. O' Halloran used, once a day, either the sulphate of copper in substance, rubbing it on the inner surface of the eyelids after everting them ; or the nitrate of silver, dropping a ten grain solution of it on the eye. He also applied foment- ations, and gave purgatives. If the symptoms indicated the extension of the inflammation to internal parts of the eye, then only he directed leeches. 49. Mr. Guthrie, considering the nitrate of silver in solution to be ineffective, in the most se- vere cases, recommends an ointment, made with ten grains of this salt, reduced to an inpalpable powder, and thoroughly incorporated with a drachm of lard, to be inserted between the lids. The eyes ought previously to be well cleansed with a tepid solution of alum ; and when the ointment is inserted, the lids are to be moved freely, so that the whole conjunctiva receives it. If the membrane become white, it is satisfac- torily applied ; if not, the ointment should be rubbed on the inside of the lids. He also directs the patient to be bled fully, and until an im- pression is made upon the pulse; he employs warm narcotic fomentations to the eye; exhibits an opiate internally; injects, from time to time, a weak solution of alum under the lids, to wash away the discharge; and applies a mild ointment to them at night, to prevent their adhering toge- ther. The next morning, the discharge is again 860 EYE — Purulent Ophthalmia in Adults. to be removed, and the strong ointment re-applied, so that the new action that should be set up may not cease ; the other remedies are likewise to be continued. In addition to these, he gives calo- mel and opium, so as to affect the mouth; and the other more common remedies. 50. As different writers prescribe different astringents, and of various grades of strength, it were desirable that some more precise knowledge were attained as to which is the safest and most efficient. Dr. Jacob, after passing acetate of lead, alum, sulphate of copper, sulphate of zinc, corrosive sublimate, and lunar caustic, in review, decides in favour of the undiluted liquor plumbi acetatis, and strong solutions of alum, or of the nitrate of silver; which, however, he recom- mends after the painfully acute stage has passed, and in the chronic or atonic state of the com- plaint. Mr. Mackenzie directs a tepid solution of one gram of corrosive sublimate in eight ounces of water, to be injected under the lids, for the purpose of cleaning the eyes; and,"as an astringent, four grains of the nitrate of silver, or six of the sulphate of copper, dissolved in an ounce of distilled water. The solution of alum, or ofthe oxymuriate of mercury (j.— ij. gr. to % j.) may likewise be tried. Mueller prescribes one, two, or three drops of sulphuric acid, or two or three grains of acetate of copper, in an ounce of water. Mr. Briggs states, that a minute quan- tity ofthe oleum terebinthinae introduced between the lids every morning, on the point of a camel- hair pencil, the eye being afterwards bathed with cold water, is most efficacious in checking the profuse discharge. 51. It will be observed, from the foregoing, that some difference of opinion exists as to when the use of active astringents should be com- menced. The majority of authorities, as Ed- mondston,Vetch, Mackenzie, Lawrence, Jacob, &c, resorting to local depletions, and soothing or anodyne applications, in the early, acutely painful, or active inflammatory stage, and to strong astringents, when this stage is re- moved, and the chronic or atonic condition has commenced ; whilst some military authorities, as Melin, O'HALLORAN.andGuthrie, advise the adoption of powerful astringents from the beginning. I agree, however, with the former; and with them consider, that the effects of astrin- gents should be carefully watched, when early, or even at first employed; and, if the redness be increased by them, that they should be laid aside for a time, and antiphlogistic remedies adopted. The citrine or red precipitate ointment should be applied to the edges ofthe lids at night. 52. In the dark races, astringents ought to be early and energetically employed. Among the negro tribes, vegetable astringents and stimulants, especially lime-juice, are entirely confided in. The astringents above noticed are, however, equally appropriate in them; and the addition of anodynes, particularly opium and camphor, is also of service, with pure air, and suitable diet. 53. Blisters to the nape of the neck or behind the ears, are sometimes serviceable, especially when kept open for some time. When the pain is very distressing in the acute stage, relief is afforded by the steam of hot water, to which laudanum and camphor have been added; and the vinum opii is often a useful application, when the conjunctiva is relaxed and painful upon the disappearance of the discharge. Evacuation of the aqueous humour by incision has been recommended by Mr. Wardrop, in order to remove the burst- ing pain in the eyes and forehead, and practised in twenty-three cases by Mr. Macgregor, from a dread of rupture of the cornea. In the advanced stage of the disease, exercise in the open air, exposure of the eye to as much light as it will bear, and the use of gentle tonics, with a free state of all the excretions, are serviceable. If, after depletions, the eye becomes irritable, or the pain intermittent or periodical, the preparations of bark, with the mineral adds, as Mu kllk r ad- vises, will be of benefit. If ulceration of the cornea have commenced, a tonic and stimulating treatment is required, especially if it spread and be attended by debility. When ectropium ofthe lower lid remains after the inflammation is gone, and presents a red fleshy mass, Mr. Lawrence directs the application of the nitrate of silver in substance to it. 54. (b) Treatment ofthe milder grades.— If the inflammation have extended to the conjunctiva oculi, however slight, local depletion, low diet, and purgatives should be directed. When active disorder is removed by these, the application of astringents to the diseased surface of the eyelids should be entered upon, and continued until the morbid state of this part described above (§ 43.) is entirely removed. The solution of alum, or of nitrate of silver, or of sulphate of copper, the strength of which should be gradually increased, or the undiluted liquor plumbi, ought to be drop- ped into the eye, once or twice a day, th/; citrine ointment being applied to the margins of the lids at night. Exercise in the open air, free exposure of the eyes, and due regulation of all the natural functions, are beneficial. Mueller recommends mercurial ointments to be rubbed over the diseased surface of the lids once or twice daily. 55. When the palpebral conjunctiva becomes altered, or granulated, in the chronic state, as above described (§ 43.), very active local means are necessary, as the irritation occasioned by the morbid surface produces vascularity and opa- city of the cornea, or loosening and thickening of its conjunctival layer — or pannus. With the change in the surface of the eye-lids, may be associated some one of the unfavourable results ofthe more violent attacks, as leucoma, synechia anterior, staphyloma, &c.— Mr. Lawrence re- marks that, if the globe be free from irritation, the astringents already specified, particularly a solution of twenty or thirty grains of nitrate of silver in an ounce of water, should be applied to the granulated surface, with a camel-hair pencil: the lids being everted. If this be not sufficient, escharotics, beginning with the weaker, and pro- ceeding to l he strongest, must be used. In order to prevent their injurious action on the conjunc- tiva oculi, the lids should be everted, the diseased part only touched, and they ought to be kept everted until the effect is produced. The .acetate of copper, the sulphate of copper, or the nitrate of silver — the strongest — should be lightly ap- plied to the granulated surface, previously freed from moisture; and, after waiting a minute or two, the lid should be carefully washed and re- stored. These applications cause severe pain EYE — Gonorrheal Ophthalmia. 861 redness, and swelling, with increased discharge, and should not be repeated until these effects have disappeared, winch may not take place for five, seven, or eight days. In the intervals of the escharotics, some astringent solution may be applied. Mr. Lawrence and Professor Wal- ther do not speak very favourably of this plan: and are more disposed to depend upon antiphlo- gistic means in the first instance, and the sub- sequent use of astringents, as above directed, with regulation of diet and of the digestive or- gans, residence in a pure air, exercise, and a moderate use ofthe org-in. Rapid improvement, Mr. Lawrence states, sometimes has followed the substitution of soothing applications for strong astringents. C. Gonorrheal Ophthalmia. — Syn. Cto- norrhceal Inflammation of the Conjunctiva; Specific Ophthalmia; Conjunctivitis speci- fica ; Ophthalmia Gonorrhoica vera, Beer. 56. This is a violent inflammation of the mu- cous membrane ofthe eyelids and globe, attended with a profuse discharge of a fluid closely resem- bling that which issues from the urethra in gonor- rhata, and occurring in some kind of connection with that complaint. — It is the most violent and rapidly destructive inflammation to which the eye is subject ; fortunately it is one of the most rare. It sometimes destroys the eye within a very short time ; or irreparably injures it before medical aid is resorted to, especially in the lower classes. Mr. Mackenzie divides it into—1st, that from in- oculation; 2d, from metastasis ; and, 3d, without inoculation or metastasis. Mr. Lawrence dis- tinguishes three forms:—a. Acute gonorrhceal in- flammation ofthe conjunctiva; —6. Mild inflam- mation of this membrane ; — and, c. Gonorrhceal inflammation of the sclerotic coat. I shall here consider chiefly the former ; the third form being merely rheumatic ophthalmia, occurring, like other rheumatic affections, in connection with gonorrhoea. 57. a. Symptoms and Progress.—Acute gonor- rhceal ophthalmia presents all the fully developed characters of purulent ophthalmia. Mr. Law- rence distinguishes three stages ; which, how- ever, are not very clearly evinced, although the division is judicious. In the first stage, which is short, the inflammation is confined to the con- junctiva, and is attended with a sensation of sand in the eye, and soreness, stiffness, uneasiness on exposure to light, and a thin whitish mucous secretion. Extreme vascular congestion, intense and general redness, excessive tumefaction of the conjunctiva, great chemosis, and swelling of the lids, supervene ; especially as the disease ap- proaches the second stage, which is characterised by a profuse discharge of thick yellow matter, closely resembling in its appearance, and in the stain it communicates to linen, the gonorrhceal secretion. When the discharge is established, the inflammation causes effusion into the cellular tissue connecting the conjunctiva to the sur- rounding parts. Hence the very remarkable chemosis, which is sometimes so extreme, as to overlap or hide the cornea; and the palpebral swelling and enlargement, which is occasionally very great. The affection- soon extends to the cornea, constituting the third stage, with ago- nising pain in the globe, orbit, and head, aug- mented on exposure to light, and attended by I symptomatic inflammatory fever. The danger to the organ is now most imminent. The swelling ofthe lids and chemosis render it difficult, or even impossible, to obtain a view of the cornea. When this is the case, attempts to attain this end should | not be made so as to increase the symptoms. Although pain is most acute in both the eye and i head, as in other instances when the unyielding cornea is the seat of inflammation ; and although patients often complain of burning pain, of ten- sion as if the eye would burst, with deep-seated suffering extending to the brow, forehead, and head, there are some iustances in which little or no pain is felt. The symptoms are, however, not equally violent through the whole course of the complaint ; and the duration of the stages varies with the constitution and health of the patient, and the treatment adopted. The first and second, particularly the first, usually passes away rapidly. 5S. 6. Consequences.—The immediate effects ofthe inflammation on the cornea are sloughing, suppuration, ulceration, and interstitial depo- sition ; these changes leading to escape of the humours and collapse of the globe, obliteration of the anterior chimber, and flattening of the front ofthe eye, staphyloma, prolapse of the iris, obliteration of the pupil, opacity of the cornea, and anterior adhesion of the iris. Sufficient notice has already been taken of each of these lesions; as they do not differ from those super- vening upon the other varieties of purulent oph- thalmia, although they more rapidly appear, and in severer forms, than in them. 59. c. Diagnosis.—The severest grade of puru- lent ophthalmia closely resembles the acute gonor- rheal. In the latter, however, the swelling of the conjunctiva oculi is greater, and that of the eyelids somewhat less, than in the former. The discharge, however, is thicker, and perhaps more abundant, and the constitutional disturbance greater, in the gonorrhceal, in which the peculiar granulated change of the conjunctiva of the lids does not occur. In purulent ophthalmia, the dis- ease begins in the lids, and advances gradually ; but in the gonorrhoeal, it seems to commence in the conjunctiva oculi: in one case, Mr. Law rf.ncf. saw it distinctly begin there ; and it at tacks most violently and proceeds most rapidly. The former generally continues long, affects both eyes, remits, or returns, rarely destroys the eye by sloughing, and is much less destructive: whilst the latter more frequently affects only one eye, and the cornea is much oftener destroyed by sloughing. This disease is uncommon, occurs in single instances, and in persons who have had, or who still have, gonorrhoea ; whilst purulent ophthalmia usually affects numbers, particularly when many live together. 60. d. Prognosis.—Nine cases out of fourteen related by Mr. Lawrence in his treatise on this disease, were seated in one eye; out of the four- teen, loss of vision took place in nine cases from sloughing, suppuration, or opacity of the cornea. In two cases, one eye was lost and the other recovered. Sight was restored in the other five, with partial opacity of the cornea and anterior adhesion ofthe iris in three of the number. This writer adds, that so short a period intervenes between the commencement and full develop- ment of the complaint, that irreparable mischief 85 862 EYE — Gonorrhceal Ophthalmia. is generally done to the eye before aid is resorted to. In the first or second stage, its progress may be arrested ; but supcess even thus early must not be reckoned upon. If the cornea still possess its natural clearness, the eye may be Baved ; but if it have become hazy or dull, and particularly if it be white or nebulous, serious consequences will ensue. Sight may, however, be restored after partial sloughing of the cornea ; and ulceration may occur in its circumference without injury to vision. When both eyes are successively attacked, the disease is often less severe in the second, which, therefore, is saved ; but exceptions to this occasionally occur, the sight of both being lost 61. e. Causes. — Dr. Vetch found that the matter of acute purulent ophthalmia, applied to the urethra of the same individual, excited no disease ; but that, when it was applied to the urethra of another person, it produced a virulent gonorrhoea : he therefore infers that the matter from the urethra, coming in contact with the eye of the same individual, would not occasion gonorrhceal ophthalmia. But Mr. Mackenzie, Mr. Lawrence, and Dr. Jacob, adduce cases from their own practice, which were produced in this way, and refer to others from Wardrop, Astruc, Allan, and Foot. It has been inci- dentally mentioned by Scarpa and Beer, that gonorrhceal matter applied to the eye excites only slight inflammation ; but they do not refer to the source whence it was derived—whether from the same person or from another. The cases ob- served by Lawrence and the other writers just mentioned, show that this statement does not hold in respect of the same person, and that he may infect himself, although such infection is not so frequent, as the inattention of gonorrhceal patients, particularly in the lower classes, would lead us to expect; and the experience of Ward- rop, Delpech, Bacot, Allan, and Mac- kenzie fully proves that the disease may be caused by the application of gonorrhceal matter from a different person, although, for obvious rea- sons, this cannot be a frequent occurrence. It is, therefore, placed beyond doubt, by the cases ob- served by the above writers, that the complaint may be caused by the contact of gonorrhceal mat- ter— 1st, from the same individual, and, 2dly, from another. But as, in the greater proportion of cases of gonorrhceal ophthalmia, no application of matter, either from the same or another in- dividual, can be traced, in what other way does the disease arise ? It has been very generally imputed to metastasis in all such ; and the dis- charge from the urethra has been said to be sup- pressed by St. Yves, Richter, Scarpa, and Beer, but erroneously, as contended by Del- pech and Lawrence. In the cases which this last writer has recorded, the discharge was not stopped in any one, although it was generally less- ened, but in some not at all. He therefore con- cludes that, since the complaint may occur while the discharge from the urethra continues, and since it does not take place when that discharge is stopped, we cannot admit that it owes its origin to the cessation of the urethral discharge. This supposed metastatic form he refers to the state ofthe constitution, considering it as analogous to those successive attacks of different pails which are observed in gout and rheumatism ; and he i remarks that, although direct infection operates equally on the eyes of both sexes, this particular form seems confined to the male. Beer says that he has observed it only in young, robust, and plethoric men. 62./. Treatment.—The antiphlogistic plan, and particularly vascular depletion, has been car- ried to the utmost extent, sometimes with com- plete, but as often with only partial, success. Of six cases which Mr. Lawrence saw at an early period, and treated by extensive depletion, general and local, loss ofthe eye occurred in one only, — a most satisfactory evidence of the pro- I priety of the practice. But whenever the disease ' comes late under treatment, no plan can succeed, so violent and rapid is the disease. The appli- cation of strong astringents and escharotics to the eye, in order to arrest its progress, has been ad- vised, as its consequences have been so destruc- tive to the organ; and the nitrate of silver oint- ment, already described (§ 49.), has been re- commended by Mr. Guthrie. The success of this practice in the severe purulent ophthalmia, warrants its adoption in this ; and active deple- tions, found so successful by Mr. Lawrence, in an early stage, may precede it. One circum- stance, however, may militate against our infer- ences in favour of it, namely, the original and principal seat of disease being in the palpebral conjunctiva, in purulent, and in the conjunctiva oculi, in gonorrhceal, ophthalmia, the pathological states are not therefore the same in both. Not- withstanding, both modes of practice may be conjoined with advantage, as Dr. Jacob suggests. The oleum terebinthinoe, dropped into the eye, is deserving of trial. 63. Large and repeated bloodlettings from the arm or jugular vein, followed by local depletion and the remedies above advised (§ 62.), are, in the present state of our knowledge, most to be depended upon. But if sloughing or suppura- tion of the cornea have occurred, this treatment will be of no service. Mr. Lawrence has seen mercury employed without any advantage, and he places no reliance on the reproduction of the urethral discharge, as advised by Richter, Scarpa, and Beer. He also thinks blisters to be of little use. The eyes should be very fre- quently cleansed by the usual means. When the inflammatory symptoms have been com- pletely and quickly subdued, the effects will pass off in a little time without astringents and tonics ; but when the conjunctiva becomes pale and flabby, and the patient pallid and weak, the pu- rulent discharge being still abundant, astringents locally, aud tonics internally, are usually recom- mended. When sloughing or ulceration of the cornea is attended by signs of great depression, quinine and generous diet are necessary, and astringent lotions are sometimes of service. Mr. Lawrence prefers a solution of from two to ten grains of alum in an ounce of water, the solution of the nitrate of silver, and undiluted liquor plum- bi acetatis. 64. g. Mild gonorrheal Inflammation of the Conjunctiva.—Mr. Lawrence has described a very slight variety of gonorrhceal ophthalmia, consisting of external redness of a bright scarlet tint, with distension of the superficial vessels ofthe globe, and increased mucous secretion. In still slighter attacks, the redness is not deep nor gene- F.YE—• Scrofulous Ophthalmia. 863 ral, the membrane is not swollen, the secretion is hut little increased, and the pain is trifling. The severer grades of this form approach to those of acute purulent ophthalmia, the conjunctiva being red throughout, tumefied, and secreting a copious yellow mucous matter. These milder states of the disease usually occur in patients with gonorrhoea of a rheumatic or gouty diathe- sis, and most frequently in conjunction with rheu- matic affections consequent upon the gonorrhceal disease of the urethra. 65. h. Tie Treatment consists of antiphlogis- tic remedies, co-ordinate with the severity of the attack, and the strength of the patient; followed by astringent applications — the best of which, iu the opinion of Mr. Lawrence, is the solution of lunar caustic. 66. D. Pustular Ophthalmia—Pustular Inflammation of the Conjunctiva. — a. Inflam- mation of the conjunctiva, with small pustules, or phlyctenule, sometimes occurs from cold or other causes, and resembles, in its appearance, and occurrence chiefly in persons before puberty, the strumous form of the disease. But it is met with in those who are not strumous; and it does not exhibit the other symptoms of scrofulous or catarrhal ophthalmia : it therefore constitutes a distinct variety. It is characterised by distended fasciculi of vessels upon the conjunctiva, which run towards the cornea, either terminating at its margin, or extending a short way over this boun- dary, and there form a small reddish or whitish elevation. This elevation contains, at first, a little watery fluid (Phlyctente), but it afterwards assumes a pustular appearance. Sometimes only one is observed, at others there are a greater number extending around the margin of the cornea. They are usually small; but, when single, they are occasionally as large as a split pea. They are not attended by much pain or intolerance of light If the complaint is neglect- ed, the pustules may ulcerate, and the ulceration 67. b. The Treatment consists in the applica- tion of leeches and blisters in the more acute ca- ses. The disorder generally disappears, under or- dinary circumstances, without ulcerating, when due attention is paid to the secretions and excre- tions; mild aperients and a saturnine lotion are usually all that are required. 68. E. Scrofulous Ophthalmia. — Syn. Scrofulous Inflammation of the Conjunctiva; Strumous Ophth.; Inflam. ofthe Conjunctiva in Scrofulous Constitutions. — Scrofulous children are very liable to this disease. It is sometimes the first manifestation of the strumous diathesis ; and, if neglected, it often becomes the source of impaired, or entirely lost, vision. It seldom at- tacks infants before weaning ; but, from that period to nine or ten years of age, it is very pre- valent; as many as three fourths of the cases of ophthalmia at this period being scrofulous. Some- times only one eye is affected, at other times both are inflamed from the first ; and very often the disease passes from the one to the other. When both are simultaneously attacked, one is usually much worse than the other. 69. u. Causes. — a. The predispodng causes ate those of Scrofula (see that article) which may be very generally referred to climate, air, exercise, food; and to the habits, health, and con- stitution of the parents. — <9. The exriting causes are exposure to cold and moisture, injuries to the eye, irritating matters in the air, excessive use of the organ; the common causes of catarrhal oph- thalmia, or an attack of this complaint; teething, hooping-cough, and more especially cow-pox, ex- anthematous diseases, and porriginous erup- tions on the scalp and face. Measles and small- pox very frequently excite it; and Juengken represents vaccination as one of its most common causes. He disapproves of the practice of vacci- nating children in the first year; as he considers that a certain degree of constitutional vigor is re- quired to remove from the system the poison in- troduced by inoculation; and that, when the child is weak or too young, the morbific matter is not thrown off, and calls into action the scrofu- lous diathesis. Beer states that, in Breslau, where ninety-five cases out of one hundred of ophthalmia in children are scrofulous, the streets are narrow and filthy, and the food of the poorer families unwholesome. Mr. Lawrence and Mr. Mackenzie think that the complaints de- scribed by Mr. Wardrop under the denomina- tion of " Exanthematous Ophthalmia," and by Mr. Christian under the name of " Porrigi- nous Ophthalmia,'" belong in every essential re- spect to the disorder now being considered. 70. 6. Symptoms and Course. — External red- ness is often inconsiderable, and most apparent at first in the linings of the lids. It is generally only partial in the conjunctiva oculi, particular enlarg- ed vessels, or fasciculi of vessels, running in this situation towards the cornea, and extending over its margin, or stopping short of it. Where the fasciculi terminate, small phlyctena or pustules form, and contain either a little clear or a yellow- ish fluid. These pustules may be seated on the sclerotica or cornea, but more frequently on the boundary between them; and may be single, or several. Their presence has induced Mr. Mac- kenzie to view strumous ophthalmia as an erup- tive disease.— The intolerance of light is ex- treme, and characteristic of the complaint. The lids are spasmodically closed, and resist any at- tempt to open them; and, when opened, the cor- nea is turned up under the edge of the orbit, and away from the light. The child puts all the mus- cles into action to protect the organ; and hence a peculiar and characteristic physiognomy is as- sumed. It seeks the darkest part of the room, or presses its face against the pillow in bed, to es- cape from the light. This excessive sensibility of the retina (Photophobia scrofulosa) is not caused by inflammation, nor is redness even essential to it; for it is often very remarkable where the eye appears almost natural ; and the child opens its eyes and sees as well as usual in the dusk. This disordered sensibility is altogether sympathetic and functional; and is dependent, as Mr. Lawrence thinks, on the condition of the alimentary canal. I would impute it rather to the state of the or- ganic nervous system. 71. There is a copious flow of tears at the commencement. The external surface of the organ suffers great irritation, extending to the la- chrymal gland, so that when we attempt to examine the eye, or to expose it to the light, there is a copious discharge of scalding tears, causing redness of the lids, and excoriating them and the face. Owing to the itching and soreness 864 EYE —Scrofulous Ophthalmia. thereby occasioned, the child rubs or scratches the parts, which become sore and pustular, and produce a discharge which encrusts ; the affec- tion ultimately extending over the face and forehead, and in its worst form resembling crus- ta lactea and porrigo larvalis. The edges of the lids are often red, swollen, and painful. There are sometimes an acrid secretion from, and excoriation of, the nostrils ; with redness and swelling of the alee nasi and upper lip. The ears are frequently red and sore, or exco- riated behind, and the absorbent glands of the neck are swollen. The bowels are costive, the tongue white or furred, the abdomen distended, the breath fcetid, the appetite is morbid, the head and sometimes the skin are hot, and the child is restless and grinds its teeth when asleep. The symptoms are worse during the day, but re- mit somewhat in the dusk of evening. The in- flammation of the eye may suddenly subside, and return as suddenly; and very slight exciting causes will bring back the complaint; which may thus continue with slight intermission for months, or even for years. The affection of the eyes may also alternate with some other disorder, or symp- toms, in remote parts. In the more chronic cases, the health suffers greatly from seclusion from light, air, and exercise; and the patient becomes pale, etiolated, and sickly, with a dry and harsh skin. 72. c. The Consequences of the disease on the cornea are often serious, although the external redness may not be great. The phlyctenular or pustular elevations in the cornea may subside, leaving slight opadty, or considerable thickening of the corneal conjunctiva with greater and more permanent opacity; but they more com- monly ulcerate, in an irregular form, and with a ragged edge, the ulcers sometimes extending superficially, or making their way through the cornea to the anterior chamber, occasioning pro- lapse of the iris. The vessels passing over the cornea may, without forming pustules, occasion thickening and opacity, which may proceed so far as to render the whole corneal covering thick and vascular (Pannus). Opacity from interstitial de- position may also occur, either with or without enlargement of the proper corneal vessels; and, according to Dr. Froriep, a brownish red dis- colouration, from interstitial effusion of blood, may supervene. In addition to the opacity, the external layers of the cornea may yield from the pressure from behind, and form an external pro- tuberance (Staphyloma); or adhesion of the iris to the internal surface of the cornea may take place. In some instances, the inflammation ex- tends to the sclerotic coat and iris, and even to the parts seated behind them. This occurs most fre- quently in prolonged or after repeated attacks; and occasionally is followed by structural change of these parts, or by dropsical enlargement of the globe. 73. d. Diagnosis.—The extreme intolerance of light, and copious flow of tears in connection with the trifling external redness, the pustular elevations of the conjunctiva, sufficiently dis- tinguish this affection, which frequently, also, co-exists with enlargement of the glands and scro- fulous irritation of the nostrils, lips, behind the ears, and in other parts of the body. In many instances, however, of conjunctivitis in children, it is difficult to draw a distinction between the j common and scrofulous forms of the disease; ] the characters of the one gradually merging into those of the other. This is more especially the case when the affection of the eyes is associated with, or consequent upon, either acute or chronic | cutaneous eruptions, particularly such as affect the scalp and face. 74. e. The Prognosis is favourable, if the cornea be not affected, or if superficial or slight opacity, owing to deposition between its lamina?, only be present. Mere vascularity of the cornea will disappear; but if it be attended by thickening and opacity, the change will be more or less per- manent. If ulceration have taken place to con- siderable depth or extent in the cornea, and es- pecially if it be accompanied with affection of the iris, or lesion of the sclerotic coat, vision will be more or less impaired. 75. /. Treatment. — a. Constitutional or in- ternal means are most important in this complaint. After the bowels have been freely evacuated, a course of tonics should be prescribed, with alter- atives, to promote and improve the various secre- tions. A full dose of calomel and rhubarb, and afterwards equal quantities of the compound in- fusions of gentian and senna, or the compound decoction of aloes, repeated according to circum- stances, will be most serviceable. In some cases, an emetic will advantageously precede the purga- tives. I lav ing thereby evacuated morbid matters, and excited the secreting and excreting viscera, tonics, especially the sulphate of quinine, will be productive of the greatest benefit. During thjf' course of tonics, the hydrargyrum cum creta should be given, on alternate nights, with the sub-carbonate of potash and rhubarb or jalap. If the skin be pale, or the child languid and etiolated, the preparations of iron — especially the tinctura ferri ammoniata, the vinum ferri, the ferrum tartarizatum — may be preferred. An electuary of carbonate of iron, confection of senna, and treacle, may occasionally be substi- tuted — particularly on the day following that on which the powder was taken. In some in- stances, the decoction of bark, with sulphuric add, may be alternated with these tonics, especially after mercurials have been laid aside. Cascarilla with soda, or any of the tonic infusions, with small doses of the chlorate of potash, may like- wise be tried. 76. p. Regimen and diet are most important items in the treatment. The patient should be warmly clothed, and take regular exercise in the open air, particularly when it is dry and bracing. Change of air, occasionally to the sea-side; and warm, tepid, or cold bathing, are also beneficial. In weak or irritable children, warm or tepid bathing, salt having been added to the water, or in sea water, should be first adopted; and cold bathing tried, as the health improves. The diet should be duly regulated; animal food in mo- derate quantity, suitable vegetables, and ripe baked fruits, being allowed; but all fermented liquors, indigestible substances, and rich crusts or pastry ought to be withheld. The usual fari- naceous food should always constitute a chief part of the diet. The child ought to wear through the day a dark shade before the eyes; and sleep in a dark but well-aired roonvwitfiN the head | considerably raised. >>. NATIONAL LIBRARY OF MEDICINE NLM DDTflfiMDT 5 I'HwliUh NLM009884095 0334