'sr- :rjf,^"-:,'.,':v..;':>"' ■ "'•HW-H'll rt. •■I.r.. !. ' «<♦ »6rji^,fir ,,,,, ,„, .,'.,'.'. '/ •n]RS^'lfSjfv,*r;i<-«"-;"' >-■"•■■ ■•■•■•■......'• V ^^j^......., S^^Xi^W^ ^r\y/^v ./:;.•■ v:"--.'. :'.':.;■ • • ''■■■■ ... . :..... . J22r/«'»<':,!„''t'••;■) ,'t •■ ■■•:-<■ •■ ., , ,. . r. ■■■ • •■.....,... , . ' fepp;^K.r-^^-:h-;:•:^■'■'■ :■:.-.■ ■'"■•:■:■,:' ' 2Jtf''''rK<'lA'/..!.!'HT • t'.',.. , . ,',* , , :, :"' • • •. , ... ,■ • ■ . . ^te&^B^:^v; •-'■^■■'•i^. •';;:■: •■■'.',-, :■ ::•:: ::■••: J^^^ 5? litf*H^-,^'..JVi>C-»yi-:;-V',i';; :' ■■•<■'''"■'' '•.'.,■',:':.', ■ • '■■• '■>' ■■' t^Vv^AHt^.^, ^.^v^.; ;:',y.;yr.-;. ,; -; ^"V^v.;^;<^v/;::::;!r ;■.- Vv-;' -^ 9W8fefe ;•; ■•»* :^ .• y:v'-:" ••' • :•!'•.:•:; ■■": 52Ky^'^'^-«'t-m''.-i' ,- ■'■■.•r"-,'i ■'■ '■'.::■; '■.-■■" v •' ■ '' ^^-.■jwflV.; v"'^; ;•;• y:n,::.■•■■ v; ■:■. ■:••.;.■/ .■ • v.....;.. W«^*-t*r^^^^ ■/• v.:-.;•'•••,.'': '■:■■■■■ ••.. •■: ... aM^n^r^if;^• .^^^';;;•■ /.• ;• ■ ■:•:•:■;■' • '■■•■■ ■. . . ■''• • • ^vvfe'1^'.''.'''''/ .;•.■•■■■.■ .".■' ■:,•■■• ...-.■ itM'vnHVi ''si, ■ ■•• • .>■■'.;,;.•. . • frr-W/&* : ■- ' ';•./• ' •■:. .:■■■ ■. ..■. ■ .:■ ■fit'-'ri /i^, A \ DICTIONARY . V OF PRACTICAL MEDICINE: COMPRISING GENERAL PATHOLOGY, THE NATURE AND TREATMENT OF DISEASES, MORBID STRUCTURES, AND THE DISORDERS ESPECIALLY INCIDENTAL TO CLIMATES, TO THE SEX, AND TO THE DIFFERENT EPOCHS OF LIFE; WITH NUMEROUS PRESCRIPTIONS FOR THE MEDICINES RECOMMENDED, A CLASSIFICATION OF DISEASES ACCORDING TO PATHOLOGICAL PRIN- CIPLES, A COPIOUS BIBLIOGRAPHY, WITH REFERENCES; I AND AN %LppzntHv of &j>j)rofoe& jFormulae: the whole forming a library of pathology and practical medicine, and a digest of medical literature. CAL LITJffR BY JAMES COPLAND, M.D. Consulting Physician to Queen Charlotte's Lying in Hospital; Senior Physician to the Royal Infirmary for Diseases of Children ; Member of the Royal College of Physicians, London ; Member of the Medical and Chirurgical Societies of London and Berlin, etc. EDITED, WITH ADDITIONS, BY CHARLES A. LEE, M.D. NEW-YORK: HARPER & BROTHERS, PUBLISHERS, 82 CLIFF STREET. 1845. V. 3 Entered, according to Act of Congress, in the year Harper & Brothers, In the Clerk's Office of the Southern District of New-York * 1 r 1843 by ' I CONTENTS. EYE—Exanthematous Ophthalmia - 1009 Inflammation of the Sclerotic Coat, . Lond., 1785.—D. Busch, De Usu Reined. Topicorum in Ocul. Morbis. Hake, 1789. —W. Rowley. Treatise on One Hundred and Eighteen Prin- cipal Diseases of the Eyes. Lond., 1790. — G. J. Beer, Ophlhalmologia Pathologica, sect, i., Phlogosis Oculi. Lips., 1800.—/. P. Frank, De Curand. Homin. Morbis, lib. ii., p. 76.—Hynam, in Mem. of Med. Soc. of London, vol. v., p. 325 (Details his own case of chronic ophth., which was cured by the fumes and oil of turpentine applied to the eye). —iV. E. Moure, Treatise on Ophthalmy and those Diseases which are introduced by it, 8vo. Lond., 1800.—G J. Beer, Bibliotheoa Ophthalmica, in qua Scripta ad Morbos Ocul. far. a Reruin Imtiis usque ad tinem Anni 1797, breviter re- cens, dec, 4 torn., 4to. Wien., 1793-1793.—Fischer, Ophth. Pathologica, seu de Cognoscendis et Curandis Organi Sen- sorii Affertionibus.sect. i.,8vo. Leips., 1800. — Wainwright, On the Use of Belladonna in Ophth., in Med. and Phys. Joum., vol. iv., p. 5.—A. Edmonslon, A Treatise on the Va- rieties, and Consequences, and Treatment of Ophthalmia, 8vo. Edin., 1806.—C. Himly, Ophthalmolog. Beobachtung., &c, 8vo. Frank, u. M., 1801 ; et Einleitung in die Au- genheilkunde, 8vo. Jena, 1806.—Himly a^Schmidt, Ophth Bibliothek, 3 l>., 8vo. Jena, 1803-1807.—/. Spindler, Ueb Eiitzundungen d. Augcs, . Napoli, 1818.—F. Demours, Traite sur les Maladies des Yeux ire, 4 vols., 8vo. Paris, 1818.—G. Walroth, Syntagma de Oph'h. Veterum, 8vo., 1818.—C. H. Weller, Die Krankh.d. Menschl. Auges, &c, 8vo. Berl., 181'J, trans, by.Monteath, Glasg., 1821.—Guil- lie, Biblioth. Ophthalin., ou Recueil d'Observat. sur les Maladies des Yeux, f death having soon after- ward taken place. Such an occurrence could not have arisen from the effect produced upon the brain solely, or even chiefly. Indeed, I be- lieve that all agents which impress nerves of sensation, especially those of smell and taste, act more immediately and energetically upon the heart than is usually admitted. 2d. Sud- den and intense changes induced in various parts of the body may be sympathetically prop- agated to the brain and heart, or may coetane- ously affect them; as when syncope follows gangrene, or the passage of noxious matters into the circulation, or the ingestion of sedative or noxious matters, or supervenes upon affec- tions of the stomach, or occurs after the inva- sion of fever, and before reaction comes on. In these cases, however, congestion of the large vessels and right side of the heart, owing to, and associated with, depressed power of the organic nervous system, is chiefly concerned in overpowering or weakening the heart's ac- tion, and lessening the supply of blood to the brain. The increased function of remote or- gans, and the derivation of vital action from the brain or heart, or from both, as in impreg- nation and quickening in the female, and in va- rious diseases of the abdominal organs, will sometimes induce fainting. The sudden tran- sition from a recumbent to a sitting or an erect posture, in delicate or debilitated persons, is often followed by vertigo, quickly passing into swooning ; and is obviously caused by the nipid return of blood from the head, and the dimin- ished supply to this part, in conjunction with its sudden and overpowering reflux to the left side of the heart. 10. It is unnecessary to adduce every cir- cumstance that occasionally causes fainting, as they may be referred to the above heads ; and as there is scarcely an occurrence or external agent which will not. on some occasion or oth- er, however rare, induce it, when acting en- ergetically on susceptible constitutions. On many, however, of the occasions in which it has been said to occur by writers, leipothymia has been mistaken for, and confounded with, it. Thus Heberden, in stating that epileptics are liable to faint upon wakening in the morn- ing, has mistaken this state for leipothymia, which is common in the horizontal posture, sensation and respiration being nearly abolish- ed, but the pulse retaining its fulness and strength ; whereas syncope rarely comes on, and generally disappears in this posture. In epileptic patients, leipothymia often occurs both when falling asleep and on waking; but syn- cope principally on suddenly assuming the erect posture. 11. There are some occasional causes, the operation of which is not easily explained, such as warm baths, heated rooms, and overcrowd- ed assemblies ; sitting with the back to the fire, particularly at a meal; and great rarefac- tion of the atmosphere. These, probably, act chiefly on persons whose circulating fluid is deficient in quantity, by deriving it from the heart and brain. They more frequently, how- ever, occasion leipothymia and apoplexy \,r convulsions, especially in the plethoric. 12. The occasional exciting causes seldom act excepting on susceptible or predisposed con- stitutions. These are, the debilitated by scan- ty nourishment, by acute diseases and profuse discharges; persons whose circulating fluid is deficient in quantity ; the delicately constitu- ted, especially females; and peculiar idiosyn- crasies. Those who possess much sensibility and little moral courage or force of character— who have been effeminately brought up, indul- ged in childhood and youth, and unaccustomed to the contrarieties of life—are very subject to syncope. Some females, especially the hyster- ical, weak, and excessively indulged, are re- markably liable to faint from the slightest men- tal or corporeal cause ; and there is reason to believe that the liability is increased by repeti- tion or the habit of fainting. 13. Pathological Inferences. — 1. In syncope the heart's action never, perhaps, entirely ceas- es until it terminates in death. 2. In fainting from haemorrhage, cerebral influence, especial- ly the voluntary powers and volition, is abol- ished before the heart's action is reduced to its lowest state; but, unless the swoon be com- plete, sensibility and consciousness are not en- tirely suspended. 3. The like obtains in faint- ing from moral emotions and impressions made upon the senses ; cerebral influence is first di- minished, and instantly afterward the action of the heart is weakened, the weakened vascular action still farther impairing cerebral power until fainting is the result. 4. Several causes' FAINTING—Diagnosis—Treatment. 1027 both external and internal, or pathological, par- ticularly those already specified (t) 9), seem to act coetaneously and co-ordinately upon the brain and heart, through the medium of the or- ganic system of nerves ; while others of the same class of causes (§ 9) seem to influence more immediately and especially the heart through the same channel. 5. Certain causes may suddenly derive the circulating fluid to the external surface or other parts ; and the sud- den diminution of the quantity returned to the heart and propelled to the brain may induce faintness or full syncope. 6. The sudden re- flux of blood to the right side of the heart, es- pecially when it supervenes rapidly upon the states just specified, may occasion fainting, by overpowering the heart's action, and thereby diminishing the supply of blood to the brain. 7. Fainting may arise from inflammation of the heart, or effusion into the pericardium. 8. It may also occur from the imperfect action of the heart caused by deficient organic ner- vous power, particularly of the cardiac nerves, with or without dilatation of the cavities, and weakness or softness of the parietes of the or- gan. 9. It may be occasioned by circumstan- ces preventing the return of blood to the heart. To either of these last two are to be imputed the fatal cases of syncope related by Mr. Chev- alier and Mr. Worthington, in which the cavities of the heart were found empty and re- laxed, and the large veins adjoining devoid of blood. 14. Indeed, death may supervene in any of the modes in which syncope is produced, es- pecially when carried to the extreme. Thus I have seen, in two instances, a moderate dose of the acetate of morphine occasion loss of vol- untary motion, and scarcely-perceptible pulse and respiration—the characteristic phenome- na of swooning. A larger quantity might have caused death ; its operation—extended from the stomach to the heart and brain—being the same, but so great as to put an end to the func- tions of these parts. Other causes, inducing any one of the pathological states now assign- ed, may act, in favourable circumstances, and in highly predisposed persons, so energetically as to termihate altogether the vital actions; predisposition or pre-existing states of the frame, such as have been mentioned, being often as influential in producing the result as the more direct cause. 15. III. Diagnosis.—Syncope may be con- founded with apoplexy, with the seizures to which the term leipothymia is strictly applica- ble, with asphyxy, with certain states of hys- teria, and with death.—a. The strong, labour- ed, or stertorious breathing, and the full, strong pulse sufficiently distinguish apoplexy (see that article, $ 66) from fainting.—b. In leipothymia, volition and voluntary motion are abolished, and consciousness nearly or altogether; but the pulse either is not affected, or is even fuller than usual; and it is more frequently the first stage of, or followed by, epileptic and apoplec- tic seizures than true syncope. Frequently, also, leipothymia is intimately associated with epilepsy, the former being either the earlier manifestations or the lesser grade of the lat- ter.—c. In asphyxy, the actions and functions of respiration are the first to cease ; the cir- culation of venous blood continuing for some time, until, owing to the privation of pure at- mospheric air, the passage of blood through the lungs becomes obstructed, as first shown by Dr. Williams (Edin. Med. and Surg. Journ., Oct., 1823), when total arrest of the pulmonary circulation, abolition of the cerebral and ner- vous functions, and, lastly, cessation of the heart's action (see Asphyxy, y 14, et seq.), are the consequences. Respiration and circula- tion are here quite at an end ; and the counte- nance and general surface are reddish, livid, tumid, or bloated ; whereas, in syncope the face and surface are pale and collapsed, and the re- spiratory functions and circulation still contin- ue, although in a low and occasionally almost imperceptible state. In the former there is remarkable congestion of the lungs and head ; in the latter the brain is generally insufficient- ly supplied with blood ; and the circulation of the lungs, although languid, is seldom obstruct- ed, and never altogether arrested, unless a ter- mination in death supervenes. — d. Various manifestations of hysteria either very closely resemble fainting, or are in some way or other associated with it. The more remarkable phe- nomena of hysteria may follow, or precede, fainting, most frequently the former; but the loss of motion and sensation often partakes more of the characters of leipothymia than of swooning, the pulse at the wrist being but lit- tle affected. Pain under the left breast, bor- borgymi, and a sense of suffocation, which commonly precede the hysterical form of syn- cope, sufficiently mark its nature; and, even when these are not present, other signs soon manifest themselves, especially convulsions, weeping, laughing, &c. (See Hysteria.)—e. Syncope is rarely so profound as to be mistaken for death; but Portal and Chamberet, with some writers on medical jurisprudence, con- cur in thinking that it may be both so complete and prolonged as to endanger premature inter- ment in countries where the last rite is early performed. Whether or not the action of the heart, which cannot be altogether abolished even in such cases, may be detected by the stethoscope, I am unable to state; but it surely cannot continue many minutes without detec- tion upon a strict scrutiny, unless death have taken place. The state of the cornea, which is soon covered with a film, or deprived of its delicate transparency, and afterward collaps- ed ; the appearances of the thorax upon exam- ination ; the signs yielded by auscultation ; the condition of the body in respect of flexibility, &c. ; and the temperature under the armpits, &c, will generally decide the question even in the most doubtful cases. Placing a mirror be- fore the face, or down beneath the nostrils, and observing whether the former be moistened, or the latter moved, have been long popular means of ascertaining the certainty of death, as hap- pily shown by Shakspeare (Lear, act v., sc. 3, and Henry the Fourth, act iv., sc. 3.) 16. IV. Treatment.—Syncope is frequently not only its own cure, but often the means of removing the cause which induced it. When occasioned by haemorrhage, the languid state of the circulation permits the formation of co- agula, which plug the vessels, and arrest far- ther discharge ; and the loss of the voluntary 1 powers causes the patient to fall in the Very ' position which, of itself, generally restores the 1028 FAINTING-Treatment. use of his faculties, by facilitating the trans- mission of blood to the brain. The indications are, a. To remove the cause of the affection ; and, b. To recover the patient in the seizure. 17. A. For obvious reasons, the second in- tention often may be the first required, partic- ularly when called to him in the attack. The patient should be placed in the horizontal po- sition, and removed to an open and moderately cool air; and fragrant and cold water—laven- der water, Cologne water, or simple water— may be sprinkled on the face, or rubbed on the palms of the hands, &c. In more profound cases, frictions of the limbs, epigastrium, &c, may be assiduously practised in a well-venti- lated chamber ; and the usual stimuli—aether, camphor, ammonia, &c.—given internally, in moderate or appropriate quantity, as soon as the patient can swallow. The recumbent pos- ture should always be continued until recovery is complete. 18. When syncope supervenes upon blood- letting, the recumbent posture should consti- tute the whole means of restoration ; for, un- less the operation has been very injudiciously resorted to, this will be sufficient for recovery. The use of stimuli in this case will only in- crease the consequent reaction, and often ag- gravate the disease for which the depletion was employed. For syncope from diseases of the heart, a moderate and discriminating use of stimulants is often necessary; but they may be injurious if it arise from inflammation of the heart or pericardium. When it is caused by hemorrhage, stimulants are very frequently hurtful, as they interfere with the consequent changes in the vessels, preventing a return of the haemorrhage; but extreme cases and cir- cumstances occasionally arise, rendering the use of stimuli indispensable. 19. If syncope occur after parturition, either from exhaustion of nervous power, or from haemorrhage, internal and external stimuli ought not to be delayed. Swooning from hae- morrhage in the puerperal state always de- mands immediate and appropriate treatment, as it arises not only from the loss of blood, but also from exhaustion and the sudden removal of an accustomed pressure, affecting more or less all the abdominal and thoracic viscera, from the combination of the three most powerful oc- casional causes of the affection. Besides, syn- cope supervening after the recumbent posture is assumed is never devoid of danger ; and the imperfect contraction of the uterus so gen- erally connected with the production of hae- morrhage will not be remedied by the contin- uance of this state. 20. Blood-letting has been considered by some writers necessary to the cure of certain forms of syncope, especially by those who have con- founded leipothymia with it, which is often benefited by depletions. Zacutus Lusitanus relates a case in which he practised it largely ; but the fainting was there evidently connected with disease of the heart, blood-letting being often necessary in such circumstances, although requiring much discrimination, both as to its adoption and to the mode and extent of em- ploying it. In the actual state of syncope it can hardly be resorted to without risk. The practice in such cases must depend upon the inferred nature of the heart's disease. I was some years ago called by a neighbouring prac- titioner to a patient suffering from recurring syncope, vomiting of all ingesta, and severe pain in the epigastrium, with anxiety, &c. The disease was viewed as acute gastritis, and ap- propriate treatment adopted; it terminated, nevertheless, fatally in a few hours. On dis- section, evidence of intense inflammation of the pericardium, particularly the part reflected over the heart, was found. 21. When vomiting supervenes during syn- cope, a speedy removal of the affection is the consequence, unless the syncope be, as in the preceding case, a sign of a most acute and dangerous disease, wherein blood-letting should be resorted to. When fainting arises from the quantity or quality of the ingesta, the exhibition of an emetic is generally beneficial. 22. The question has been proposed by Brauser, whether blood-letting should be per- severed in or not, when it almost immediately causes syncope without any evident cause? Such cases are not infrequent in practice, and I have met with the occurrence even where venaesection appeared most requisite, and the patient by no means fearful of its performance. In a case of this kind, which lately occurred to me, copious local depletion was substituted with great benefit; but in a still more recent case the patient recovered by means of inter- nal treatment, without bleeding in any way. The question, therefore, cannot be answered in a positive manner one way or the nther; but where syncope takes place, bleeding is not re- quired in the great majority of cases, and it may be injurious. At a time when blood-let- ting was viewed as the chief remedy in fever, and directed to be performed as early as possi- ble in the disease, I had opportunities of seeing it practised in the cold stage, or previous to the development of reaction, of both the remit- tent and continued types ; but it almost in- stantly, or before two or three ounces of blood had been withdrawn, produced syncope of a profound and serious kind, and proved mani- festly hurtful. The results would have been very different had the operation been deferred to the stage of reaction ; and hence, although instant syncope, or even faintness, upon blood- letting, is an indication of its injurious ten- dency, if persevered in at the time, yet a con- sequent state of action, general or local, may arise in a very short time, in which it will be borne to a very great extent without this af- fection resulting, and will prove most bene- ficial. 23, B. The removal of the causes of the af- fection, when these are of a constitutional or structural kind, must be attempted after re- covery from the seizure. If it depend upon De- bility, the means advised in that article will be requisite ; and in other circumstances, the treatment suitable to inferred pathological con- ditions should be practised, as pointed out in the places where such conditions are more especially and appropriately considered. The prevention of a return of the affection will be most effectually secured by this procedure. Biblioo. and Refer.—Aretaeus, Acut, 1 ii c 9 — £«.«*, Tetrab.ii.s. >. c. 96 -Paulus JEgineta.'I.'ii.', c. M.-Avicenna, Canon., 1. „i., fen. ii., tract. ij.,c 6 -Ban- ?"#;• N."" "F0. °n.ni. Syncope* eadem Curatio. Paris, ibli.-Alhertim, De Affect. Cordis, 1, iii 4to Venit mS.-Wildholz, Syncope. Natura et Cura. ArgeDt,mi\ FEIGNING DISEASE. 1029 —llarceUut Donatus, 1. ii., c. I., p. 90.-Primerosius. De Morbw Mulierum, 1 iii., c. 10.-De Berger, De Dehquiis *""■"• Witeb., 1689.-ScAenc4, Observ., 1. ii., No. 219, JM.—Fort3tus,\. xvii., obs. 8, 9, lO.-Amatus Lusitanus, cent, n cur. 36.-Fa6rtciuj Htldanus, Opp., p. 990.—Za- cutui Lusitanus, Prax. Adnnr., 1. i., obs. 135.-Bone(, Se- pulchret, 1. ii., sect, x., obs. 1, 3, 9—Lancisi, De Subit. Mort., p. 136.—Riedlin, Lin. Med., 1700, p. 226. - Wedel, Ue Syncope et Leipothymia, ed when feigning is attempted. The exertions, 'however, necessary to simulate the rigours of rthe cold stage will generally be found to be jproductive of the sweating stage instead of the former. Cantharides, and various stimulants, ;are usually taken, to induce febrile symptoms ; and a temporary acceleration of pulse is often occasioned, by both sailors and soldiers, just •before the physician's visit, by striking the el- 4>ow against any hard substance. Some per- sons acquire a power of accelerating the heart's action at will. Emetics are sometimes also Tesorted to, to make the deception more com- plete ; and the tongue is artificially coloured by chalk, pipe-clay, brickdust, tobacco, brown soap, &c. When suspicion is excited, the pulse should be examined a second time on leaving the patient, and preferably in the carot- ids or temples, the state of the excretions be- ing particularly attended to. Cases of feigned fever are generally ephemeral, and a day or two of close examination generally leads to detection. 23. Gastric Affections, especially gaslral- gia and attacks of vomiting, are sometimes sim- ulated. The former is detected with great dif- ficulty, and chiefly from collateral circumstan- ces. Vomiting is generally produced by having recourse to the common emetics, or to tobacco, particularly the latter, on account of its de- pressing influence on the nervous system and circulation, and by pressure on the stomach (C. Hutchison). I met with an instance, some years ago, where it was induced at will, by the action of the abdominal muscles, without even the aid of irritating the fauces. In such cases, the state of the appetite and the appearance of the evacuations should be examined ; for, unless where tobacco has been taken to disor- der the stomach, the former is but little im- paired. In the case of vomiting at will just mentioned, the person had no sooner emptied his stomach than he proceeded to replenish it again with an appetite. Not only is vomiting produced, but farther deception sometimes is attempted by introducing various foreign sub- stances into the matters ejected. A singular case, in which a girl was said to have brought up the larvae of insects and reptiles from her stomach, is recorded in the Transactions of the Dublin College of Physicians. It afterward, however, was ascertained to have been a well- managed deception. 24. Haemorrhoids are sometimes simulated, the appearance of the haemorrhoidal tumours being imitated by means of small bladders filled or tinged with blood, and partially introduced into the rectum (Percy and Laurent). Sim- ple discharge of blood from the anus is more easily feigned, and the deception is detected with greater difficulty. 25. Hemorrhages from the Stomach, or from the Lungs, are often feigned. In order to imi- tate Haemoptysis, cough is pretended, and the saliva coloured by pricking, scratching, or suck- ing the gums, or by holding Armenian bole, brickdust, vermilion, &c, in the mouth. An attentive examination of the sputum, and of the physical and rational symptoms, will gen- erally lead to detection. Heematemesis is often feigned by swallowing bullock's blood, and soon afterward by inducing vomiting. If the quan- tity taken be considerable, vomiting will often follow without any aid. Instances of decep- tion practised in this way are mentioned by Sauvages, Metzger, and Beck. A close in- vestigation of the symptoms, and, if suspicion be occasioned, a strict surveillance, will gen- erally prevent a continuance of the imposture. 26. Heart Affections have been simulated, in order to escape from the public services. MM. Percy and Laurent state that a ligature has been found so firmly bound around the neck as to cause a livid and swollen countenance, and disorder of the heart's action. Dr. Quar- rier and Mr. Copland Hutchison ascertained that white hellebore was often used by sailors to produce this effect, vomiting, purging, syn- cope, tremours, and nervousness, followed by palpitations, beipg the usual consequences of a large dose of this substance. Mr. Dunlop states that death was occasioned in one in- FEIGNING DISEASE. 1033 stance by the use of hellebore with this inten- tion. 27. Hepatic Disorders are often feigned by soldiers in warm countries, particularly in In- dia, and by officers and others desirous of re- turning to Europe. If any doubt of the reality of the complaint exist, the person should be undressed, and carefully examined by percus- sion and the stethoscope. The absence of en- largement in the region of the liver, the com- plexion, and appearance of the surface and limbs, and the state of the pulse and respira- tion, are the circumstances which should chief- ly be considered. It ought not, however, to be overlooked that most serious disease of the liver may exist without enlargement; and this viscus may be considerably enlarged, and even rise up into the right thorax, without being felt below the ribs. Hence the propriety of having recourse to percussion and auscultation in the investigation, especially when other proofs of disease are wanting. 28. Hernia and Hydrocele have been sim- ulated by blowing air into the cellular mem- brane of the scrotum. Mr. C. Hutchison met with an instance of hernia being feigned by el- evating the testes to the external abdominal rings. Detection in cases of this kind is quite easy. 29. Hysteria is not infrequently feigned. Dr. Dunglison directs sternutatories to be em- ployed ; but the affection may be real, although they produce their usual effect. Detection is by no means easy, especially when an intelli- gent female simulates this complaint. In a case to which I was lately called, the moral circumstances and the symptoms induced me to infer deception, and I accordingly took my leave by simply stating, in the patient's hear- ing, that if recovery was not complete in a few minutes, the affusion of cold spring water over the head and neck would certainly have the desired effect. It should, however, be recol- lected that females who are really hysterical are the most prone to feign disease; this af- fection and the desire to simulate others fre- quently arising from the same cause, viz., ute- rine irritation. 30. Jaundice, notwithstanding the difficulty of the attempt, has been successfully simula- ted, particularly in France, during the late war. Conscripts employed an infusion of turmeric to tinge the skin, muriatic acid to give the evacu- ations a clay colour, and rhubarb to heighten the colour of the urine. But the white of the eye cannot be changed by art, although smoke has been tried for this purpose. Washing the surface, and preventing access to the materi- als of deception, are the chief means of detec- tion. 31. Insanity, in some one of its various forms—but most frequently mania, melancholy, and idiocy—is frequently feigned, and detec- tion is by no means easy. There can be no doubt that, in the public services, pretenders often gained their ends, and that the really af- flicted were sometimes treated as impostors. Nor can this be a matter of surprise, when the great difficulty of discrimination is considered. In the present day, madness is most common- ly feigned with the view of escaping from the punishment due to crime, and the responsibili- ty of the medical examiner is consequently 130 great. He should, therefore, hive every facil- ity afforded him, and take sufficient time to the investigation, that he may arrive at a correct conclusion. He should endeavour to obtain •from the individual a full account of himself, mark its consistency, and place an intelligent watch over him. The expression of the coun- tenance and of the eye, the gestures and man- ner, the state of the tongue, the appetite, and the evacuations, and especially the duration, continuance, or frequency of sleep, ought to be carefully observed. Certain expressions of countenance and gestures are so peculiar to the insane, that the experienced observer will infer much from them. Pretenders generally overact their parts, assume the more violent or disgusting forms of mania, do not maintain the deception when they believe themselves unobserved, recommence it in the society of others, and possess not the power of prolonged abstinence from sleep and food so generally observed in the truly insane. Sound sleep soon overpowers the pretender, whereas the insane are remarkably watchful, sleeplessness to a distressing degree often preceding the dis- ease, and always attending it throughout, for much longer periods than can ever be endured by a person in health. 32. The insane, during remissions, are desi- rous of being considered free from the malady, and often assiduously endeavour to conceal whatever may betray them; but simulators sel- dom carry their deception thus far. The real malady usually commences with slight disorder of the common modes of thinking and acting, and advances slowly through some hallucina- tions, until at last it is either fully developed, or is suddenly exasperated. The feigned dis- ease, on the contrary, presents not this course, is not preceded by sleepless or restless nights, and by a continued consideration of one topic, but appears at first in its full violence. The existence or non-existence of the causes of in- sanity, of previous attacks, of pre-existing ec- centricity of manner or thought, of hereditary tendency, of antecedent affections of the brain, of injuries of the head, &c., the character of the individual, and the motives for feigning will also be considered by the physician. Care should be taken not to infer deception because the motives for it are apparently strong ; for the circumstances constituting the motives may be the causes of the real malady. The costive state of the bowels, the large doses of medi- cine necessary to move them, the comparative insensibility of the stomach to tartarized anti- mony, the generally more frequent pulse, and the sudden and extreme irritation on any con- tradiction, observable in the maniacally insane, should not be overlooked, as they hardly admit of being feigned. Their disregard of the decen- cies, comforts, and affections of life ought also to be taken into account; for, although these signs are often also simulated, deception in re- spect of them is seldom carried so far as in the real malady. A person even of pure charac- ter, when truly insane, will often use the gross- est language, practise the greatest indecencies and brutalities, and evince the bitterest dislike of, and malice to, his friends; but simulators exhibit those symptoms only when they believe themselves watched, or before others. Dr. Haslam remarks that the melancholic states of 1034 FEIGNING DISEASE. insanity are feigned with greater difficulty than the maniacal; the one presiding principle, the ruling delusion, the unfounded aversions, and causeless attachments, the peculiar look, the solemn dignity, and the associations character- istic of the former can never be simulated so as to deceive the experienced observer. Idio- cy is most easily feigned, yet there are always a hesitation and reflection observable in the discourse of the pretender, his disordered ideas not succeeding each other with the same rapid- ity as those of a person whose understanding has been really destroyed. The simulator will also, according to Dr. Marc, repeat the same ideas, and often the same words, in order to prove his madness, that he is requested to re- peat ; whereas the truly insane will wander in- coherently from what he is desired to utter. In this form of insanity, the patient is always pusillanimous and submissive, unless during impetuous excesses, which only sometimes oc- cur, and memory and conception are both de- fective 33. It may sometimes be proper, if suspicion exists, to mention some severe remedy, or to threaten punishment. The really insane never heed these ; but those who feign will often discover, by the change in the pulse, or by looks or actions, the emotions thereby induced. Zac- chias states that a physician ordered, in the hearing of a person whom he suspected of de- ception, that he should be severely whipped ; inferring that the external irritation might be useful if the disease was real, or too severe a test if feigned. The threat was sufficient. Fodere, on leaving a female who had long succeeded in simulating insanity, said to the keeper, within hearing of the patient, "To- morrow I shall again visit her ; but if she con- tinue to howl, if she be not dressed, and her chamber not put in order, you must apply a red hot iron to her neck." This was sufficient. The very treatment most conducive to the re- covery of the really insane is the most intol- erable, if persisted in, to the simulator; who is often all at once cured upon hearing of his being about to be sent to an asylum, or of a continued and rigorous recourse to solitary confinement, low diet, and repeated counter- irritation. 34. Lameness is often feigned by sailors, sol- diers, mendicants, and convicts, by pretending contractions of the muscles, deformity, the ef- fects of fractures, and by introducing sharp bodies under the skin. For pretended contrac- tions of muscles or joints, a tourniquet may be placed above the joint, and so closely drawn as to render the muscles incapable of acting, when the joint will become moveable. The emacia- tion of the limb in these cases is no proof of their reality, as it necessarily proceeds from disuse of the limb. Previous fractures of bones is often alleged; but the cheat is readily de- tected on minute examination. Malformation, particularly curvatures of the spine, elevation of one shoulder, inversion of the feet, and shortness or distortion of a limb, are some- times simulated. There can be little difficulty in detection, on a careful examination of the naked body. Pretended distortion of a limb may be ascertained by the use of the tourniquet, or by straightening it, while the simulator's at- tention is withdrawn from it, as was done by Mr. C. Hutchison in a case which occurred to him. Instances have been met with of females who caused serious swellings and abscesses by introducing a number of needles into the parts. 35. Neuralgic, Rheumatic, and other Pains are very frequently simulated ; and detection is very difficult, as it is next to impossible to prove the absence of pain. Inconsistencies in the patient's account of his case, and contra- dictions into which he may be readily led by an artful examination, are the chief means of detection. Pain is seldom very severe or pro- longed, without being attended by certain symp- toms, according to its situation. If it affect the joints, swelling, redness, stiffness, &c, are usually the result; if it occur in any part of the abdominal cavity, the functions of diges- tion, assimilation, or excretion will be disor- dered ; if it affect the thoracic organs, circula- tion or respiration will be deranged; if it occur in the head, loss of sleep will, at least, be the consequence. The inference should depend much upon the kind of pain complained of, upon its continuance or recurrence, and the nature of the phenomena attending it. If vio- lent pain is stated to be present, and the patient, notwithstanding, has a good appetite, sleeps well, and does not lose flesh, we may doubt its reality. The effects of remedies should also be taken into the account, as well as the pa- tient's desire of, or objection to, those which are of a severe kind. But the most severe pains may long exist, even in external parts, without affecting their appearance, and be re- ferred to internal organs, without materially deranging the functions. Several instances of this kind have come within my own observa- tion. These have been usually called neural- gic ; and have often disappeared for a time, either during treatment, or without the use of any means. Many of the reputed cures of these would have taken place without any remedy whatever; but, to whatever cause the recovery is attributable, the return of the pain in some form or degree is generally observed, although of this as little as possible is said by narrators of extraordinary cures ; and sometimes a re- turn of the complaint is the least unfavourable occurrence, a more dangerous or even fatal malady taking its place, especially in the rheu- matic and gouty diathesis. 36. Cases have occurred which have caused suspicions of feigning, and yet the results have shown most serious internal disease. A fe- male, some years since, consulted a number of physicians respecting a most violent pain in the left side and loins, extending upward to the left mammae. One considered it neuralgic, another hysterical, a third uterine irritation; a fourth deception, probably connected with hys- teria ; and, lastly, it was attributed to spinal irritation. The appetite continued good, the urine appeared healthy, and there was no ema- ciation. After many years of suffering, the lady died; and there were found (what, indeed, might have been expected) a great number of calculi in the uriniferous ducts and pelvis of the left kidney. A celebrated preacher and theological writer long complained in a similar manner The urine was abundant, and of a good colour, and hence disease of the kidnev was not suspected by the numerous eminent FEIGNING DISEASE. 1035 men whom he consulted; but this organ was, nevertheless, found, after death, filled with cal- culi. I have met with two or three instances of the most severe pain, recurring at irregu- lar intervals, in a particular joint—in the left shoulder joint in one case, and in the right knee in another, without any apparent local or constitutional disturbance ; the tongue being clean, the bowels regular, the appetite good, and the flesh and strength undiminished. An ointment, with a large proportion of veratria, was employed for some time in one of these cases, without benefit. The most successful means in both were such as improved the di- gestive and excreting functions. These cases, in circumstances admitting of the least suspi- cion, might have been considered as feigned. 37. I have no doubt that formerly, when the pathology of the spinal chord and its mem- branes was less attended to than now, many very severe affections, occasioned by changes in this quarter, were viewed as fictitious. I lately attended an intelligent tradesman advan- ced in life, who long complained of severe pains in the thorax, darting through both sides, and often backward to between the shoulders. They were occasionally most violent, and fix- ed themselves for a time in one place, and then in another, of this cavity. The functions of circulation and excretion were unaffected, but the respiratory actions were sometimes dis- turbed. One day he was unable to get out of bed, and another he came down to his parlour. His complaints were considered chronic pleu- risy, adhesions of the pleura, rheumatism of the thoracic muscles, &c. When first called to him, I examined the thorax by auscultation and percussion. The sounds furnished by both were perfectly healthy. The liver was thought to rise rather high, and the stools were defi- cient in bile. Chronic disease of the liver was therefore suspected. Upon extending the ex- amination to the spine, two of the spinous pro- cesses of the upper dorsal vertebrae were found very prominent, and pressure in this situation caused great pain. The treatment was direct- ed accordingly, and amendment took place. These cases evince the importance of a very minute and extended examination in ascer- taining the cause of pain, and, consequently, of proving its reality. When severe pain is complained of by females in any external or in- ternal part, an opinion as to its reality or na- ture should not be given until the spine is care- fully examined, and the state of the uterine functions inquired into. The existence or non- existence of tenderness, pain, or fulness in the hypogastric, iliac, and sacral regions, indica- ting disease of the uterous or ovaria, ought also to be ascertained ; for if the least sign of disorder in any of these situations be detected, we ought not to infer deception, although it must be admitted that exaggeration, and even deception, may be practised nevertheless. 38. Ophthalmia was not infrequently produ- ced by soldiers and conscripts during the last war, by means of corrosive sublimate, powder- ed alum, quicklime, acids, salt, tobacco, and va- rious acrid powders and mechanical irritants. The extreme rapidity of the inflammation, es- pecially as respects its invasion of the con- junctiva oculi and cornea, and the circumstance of the right eye only being affected, should ex- cite suspicions. The chronic forms of ophthal- mia were also excited and kept up by extract- ing the eyelashes and applying irritants to the edges of the eyelids. When entire seclusion of the suspected patient cannot be obtained, as in the navy, the recommendation of Mr. C. Hutchison to use the strait waistcoat should be adopted. 39. Palsy and Shaking Palsy are not often feigned. If, with the loss of motion, or the continued agitation of a limb, or one half of the body, the general health appears to be good, and the excretions natural, a watch should be set upon the patient, and his actions observed when he thinks himself unnoticed. The cold affusion, electric shocks, moxas, and the actu- al cautery, will often have a wonderful effect in suspicious cases. Even the threat of hav- ing recourse to these means has been suffi- cient. In cases of simulated paralysis, detec- tion may be easily accomplished by causing sleep by opium, and then tickling, irritating, or pinching the motionless extremity. If the dis- ease be feigned, the limb will be retracted or withdrawn ; and, upon first wakenmg, it will often be used before the patient recollects him- self. 40. Polypus of the Nose has been often imi- tated, according to MM. Percy and Laurent, by French conscripts, who have succeeded by introducing the testes of cocks, or the kidneys of hares or rabits, into the nostrils, and retain- ing them there by means of sponge to which they had been fastened. 41. Pregnancy is often pretended to gratify the wishes of a husband or relations, to increase interest, to extort money from a paramour, to deprive a legal heir, to delay the execution of punishment, and to avoid labour. A careful examination of the areolae, of the mammae, of the umbilicus, and of the os uteri, will general- ly lead to detection, at least in the more ad- vanced months. (See Pregnancy.) 42. Pulmonary Diseases are not often feign- ed ; but I have met with instances—two in fe- males—in which slight symptoms have been exaggerated into the appearance of dangerous disease, particularly in the description of them, in order to accomplish particular ends. In such cases the patient has a frequent and short respiration, and a hacking cough, with little or no expectoration; complains of the pain on coughing or taking a full inspiration, and of night sweats ; evidently desires to be consid- ered very ill, but is averse from medicine, as he considers it of no use, and even resorts to various means to produce emaciation, particu- larly vinegar, the oxydes of copper, cream of tartar, tartaric acid, &c. The state of the pulse, the sounds produced by auscultation and percussion, the apparent despondency, instead of the continued and unwearied hopes of the patient, characterizing the real disease; the marked reluctance to have recourse to issues, setons, or counter-irritants, and an inquiry into the wishes of the patient as to regimen, &c, are the chief means of detection. In pri- vate practice the physician should endeavour to ascertain whether or no the treatment di- rected is strictly followed, particularly the in- sertion of issues, setons, &c.; for if these be not adopted after a confident recommendation of them, strong suspicions of deception should 1036 FEIGNING DISEASE. be entertained, and he should immediately with- draw. 43. Rectum. — Prolapsus and Fistula of the Rectum have both been simulated by conscripts and persons desirous of escaping from the pub- lic services. Ambrose Pare, Percy, and Lau- rent met with instances in which a portion of sheep's gut, or the urinary bladder filled with blood, had been partially introduced up the rectum in order to imitate prolapsus. Fis- tula has been actually produced by making an incision near the verge of the anus, and intro- ducing into it an acrid tent, particularly the root of white hellebore (Dunglison). 44. Rheumatism and Lumbago are often feigned by soldiers and sailors. Where they are complained of without swelling of joints, or acceleration of pulse in the evening, or in- creased heat of the affected part, wasting of the limb, disorder of the digestive and biliary organs, or loss of the appetite and looks, sus- picion should be excited. Dr. Cheyne remarks that those who feign this disease "give a glow- ing account of their sufferings, alleging that they have entirely lost the use of the part af- fected, which seldom happens in genuine rheu- matism. There is, for the most part, no ade- quate cause assigned for the complaint ; no relief from remedial treatment acknowledged ; and, while real rheumatic affections are aggra- vated by damp, the impostor complains equally at all times." (See $ 35.) 45. Sight.—Defects of this sense are fre- quently feigned. Short-sight may not only be pretended, but it may actually be occasioned by the use of concave glasses, in order to avoid military service. Those who are truly near- sighted frown or knit their brows habitually, when looking at objects beyond the range of distinct vision, and the crow-feet wrinkles at the outer corners of their eyes become early mark- ed. MM. Fodere, Percy, and Laurent advise that persons claiming exemption on this ac- count should be caused to read with concave glasses, the book being held at a proper dis- tance ; and without them, the book being put close to the eyes ; if they cannot read distinct- ly in both cases, the imperfection is feigned.— Night-blindness, or intermittent blindness (he- meralopia, nyctalopia), is often simulated by sailors and soldiers serving in warm climates, where the affection is common ; and it is de- tected with difficulty. The deception is prac- tised in order to avoid night duty, and has been put a stop to by associating a blind man with one who can see in the various works carried on during the night, and when the sen- tries are doubled (Cheyne). 46. Somnolency, or Sopor, has been feigned with the utmost pertinacity, in order to obtain a discharge from the public services, or to an- swer purposes of revenge, as in the instances recorded by Dr. Hennen and Mr. Dease. As cases of sopor sometimes occur, care should be taken to distinguish between the real and simulated. The former is seldom, or perhaps never unconnected with some cause of ex- haustion operating chiefly on the nervous sys- tem, or without antecedent signs of mental and physical debility, particularly defect of memory, hesitation of speech, remarkable lan- guor, &c. I lately attended, with Mr. Bushell, a gentleman about sixty years of age, who con- tinued for many weeks in a state of sopor, in- terrupted only by being talked to loudly, or by taking food. When thus roustd, he yawned, answered slowly, and instantly fell into a quiet sleep, unattended by any unnatural respiratory sound. He recovered slowly by the use of tonics and stimulants, and the occasional ex- hibition of stomachic purgatives. No cause but exhaustion of nervous and cerebral power could be assigned for the disease. Such cases, however, most frequently follow injuries of the head, attended by pressure on the brain, or the slow development of tumours within the cra- nium. Dr. G. Smith mentions the case of a soldier who feigned a state of insensibility, and resisted every kind of treatment; but on pro- posing, in his hearing, to apply red-hot iron, his pulse rose, and amendment rapidly follow- ed. A singular case of feigned sopor is de- tailed in the Edinburgh Annual Register (vol. iv., part ii., p. 159). A soldier, eighteen years of age, confined for desertion, lay, apparently insensible, from the end of April to the 8th of July, 1811. Electric shocks, the application of snuff to the nostrils, pins thrust under his fin- ger-nails, and other stimulants failed to rouse him. The sopor being thought the consequence of injury, the scalp was divided in order to as- certain the existence of depression, and the bone even scraped ! yet no complaint was made. The case was viewed as hopeless, and the man dismissed. Two days after his dis- charge he was seen cutting wood some miles from home. But wherefore should a depres- sion of the cranium be hunted out by dividing and drawing back the scalp and scraping the bone 1 One would expect that some tolerable signs of its existence should have presented themselves before such serious measures were resorted to. Can we be surprised at detection failing in such hands 1 47. Tympanitic and Emphysematous Affec- tions- have been simulated by introducing air into the digestive canal, and by inflating the cellular tissue, in the manner already stated ($ 28). MM. Percy and Laurent mention the case of a conscript who simulated an immense tympany by swallowing air; and Dr. Cheyne states that this affection was apparently caused by a number of men in the 84th regiment. The pulse, tongue, and excretions were natu- ral, but pain in the region of the liver, and over the abdomen, which was distended and tym- panitic, with insatiable thirst, were complained of. Deception being suspected, they were re- quired to take a cupful of a solution of the sul- phate of soda in weak tobacco water every four hours until it operated. Recovery was speedily effected by means of this detestable medicine ; but sixteen men had succeeded in procuring their discharge before this treatment was adopted. Dr. G. Smith states that won- derful cures were often effected in military hospitals by a medicine composed of salts, aloes, and asafcetida, given frequently in small quantities, so as to keep the taste in the mouth. The substances used to produce this tympany seem not to have been fully ascertained It was ascribed to the use of large quantities of chalk and vinegar. 48. Tumefied Leg is excited by means of an artfully-concealed ligature, and keeping the ex trcmity in a hanging posture. The writers on FEIGNING DISEASE. 1037 this subject in the Cyclopaedia of Practical Med- icine state that a case of enormous enlargement of the thigh and leg, resembling elephantiasis, was sent home from India to be discharged. A ligature was discovered, and, upon its remo- val, the swelling gradually subsided. The de- tection and prevention of such cases cannot be difficult. 49. Ulcers artificially caused were remark- ably frequent in both navy and army during the last war. They were generally produced upon the legs by various caustics or irritants, by friction with sand, by quicklime mixed with soap, by compression with metallic or other bodies, and by mineral acids. Arsenic, corro- sive sublimate, tobacco, &c., have also been used for this purpose. Mr. C. Hutchison found a halfpenny between the muscles of a leg which he removed in consequence of extensive caries of the tibia following artificially-formed ulcers. Intentional ulcerations are distinguished from the real by their borders being less callous, their surfaces more superficial and less painful, and their disposition to heal, when secured against tampering, much greater, owing to their not originating in, or accompanying, con- stitutional disorder, as in the case of real ul- cers. In order to prevent this species of de- ception, Mr. C. Hutchison had recourse to a wooden box, in which he locked up the whole limb; all other means, as marked or sealed bandages, &c, having been found insufficient against the ingenuity of malingerers. 50. The Urine presents various disorders in respect of its characters and of its excretion, which have been artificially produced or feign- ed by persons desirous of escaping from the public services, and by hysterical females. In- continence of Urine was often simulated by sail- ors and soldiers. The circumstance of this disorder occurring frequently in this class of persons, who are mostly young, or in the vig- our of life, should excite suspicions of its real- ity. The simulator generally chooses the cir- cumstances and place suitable to his purposes in allowing the urine to escape. Laurent and Percy state that the glans penis is always pale and shrivelled in real incontinence, and that the urine never comes away in a stream. M. Fodere, finding that this complaint was becom- ing epidemic in a regiment, and that blistering the perinaeum and other means did not cure it, directed the penis of every patient to be tied and the knot sealed, none but the person guard- ing them being allowed to remove the ligature. The penis was observed from time to time, to ascertain whether or no distention above the ligature existed, and whether, when it was re- moved in order to urinate, the discharge took place gutlatim, as in real incontinence, or in a stream. The expedient succeeded, and the epidemic vanished (vol. ii., p. 481). Percy and Laurent prescribed twenty lashes to the loins, with the avowed object of exciting the weakened organs. It was unnecessary to di- rect it to a second case. An army-surgeon directed a cold plunge-bath twice a day with equal success; and Mr. Hutchison, Mr. Com- yns, and Dr. Hennen caused a strong opiate to be given at night, and the length of time the urine was retained during sleep to be watched, for, in real incontinence, the urine passes away after a short time under all cir- cumstances. The patient may also be caused to undress and stand before the medical man at the time when he states that his urine usu- ally passes of. In cases of feigning, the ab- dominal muscles will be seen contracting in order to expel it. 51. Bloody Urine has been simulated by the ingestion of beet-root, madder, the extract of logwood, the fruit of the prickly pear, the In- dian fig, &c. But blood is more frequently mixed with the urine. Percy and Laurent state that conscripts have injected blood into the bladder, in order to imitate haematuria. This disease has even been occasioned by hav- ing recourse to cantharides. A boy in Staf- fordshire, in 1617, having accused a woman of bewitching him, feigned various maladies, and, among others, the excretion of black urine. The wisdom of our ancestors condemned the wom- an to be burned, as was usual in such cases; but the bishop of the diocess, suspecting im- posture, caused the boy to be watched, when he was detected dipping cotton in ink, and af- terward introducing it within the prepuce, in order to give the urine, which he publicly void- ed, its dark colour. (Mem. of Literature, vol. iv., p. 357.) 52. The excretion of Gravel, and of other substances, has likewise been feigned. In all such cases, as well as the foregoing, the per- son should be made to urinate in the presence of the physician. The real existence of gravel is ascertained beyond doubt, by close inspection and chemical analysis.* Strictures have also been feigned ; but the passage of a bougie will always ascertain their reality in the hands of an expert surgeon. Suppression and Retention of Urine have been pretended, but most fre- quently by convicts and hysterical females. The introduction of the catheter, and a strict watch, will generally show the state of the case. 53. Uterine Diseases have been feigned and exaggerated, and I believe more frequently than is commonly supposed. It was attempted in one case, in which I was, some years ago, con- sulted ; but the object becoming apparent, I withdrew. This kind of simulation is some- times adopted with an evident motive, as dis- like of a husband, &c. ; but in other cases the object is not so apparent. Dr. Thomson, of Edinburgh, mentions an instance of a female in a respectable station who pretended to pass vesicular bodies resembling hydatids from the vagina. They were ascertained to be prepared from the intestines of a pig, and were made to resemble a string of beads. 54. Varicose Veins have been caused by ligatures or pressure made in the course of the larger trunks. They may also be aggravated, when already present, in a similar way. At- tentive examination, and the means advised for ulcers (§ 49), will generally detect the de- ception, and prevent it. 55. Wounds have been both pretended and inflicted intentionally. The feigning of wounds has been sometimes practised to avoid the danger of battle, or to be mentioned in de- spatches. Means which may occasion the ap- * [For a remarkable case, in which both urine and gravel were feigned to be secreted and dischin;ed from the mouth, rectum, urethra, nose, ear, side, and umbilicus, see my edi- tion of Guy's Forensic Medicine, p. 250.] 1038 FEVER—Pathology. pearance of a contusion, as abraiding or dis- colouring the surface, are chiefly resorted to. Detection will depend upon attendant circum- stances and the acuteness of the surgeon. Mutilations, or intentional wounds, are more commonly resorted to, in order to avoid con- scription into the public services, or to obtain pensions or a discharge. They are sometimes, also, practised by slaves, mendicants, and re- vengeful persons. And wounds and injuries involuntarily received have been aggravated, and their healing interfered with, to answer particular purposes. Detection in many in- stances is difficult, but it will be necessary to consider the possibility of the patient having inflicted the wound himself, its nature and ex- tent, its relation to the alleged cause, to the probable object desired to be accomplished, and all the circumstances connected with it, before a conclusion should be arrived at. Persons in the public services, it should be remembered, occasionally assist each other in causing muti- lations, and in aggravating injuries; so that the moral as well as the physical relations of the subject should be carefully weighed in all cases. 56. I have given the sum of our knowledge as to the means of distinguishing real from feigned disease, and of preventing the conse- quences of successful deception. I have en- deavoured to avoid extraneous matters; and have not introduced amusing instances of sim- ulation, as my limits must be more usefully occupied. The importance of the subject is especially great to the naval and military med- ical officer; but it is not less so to the civil practitioner; and the success of both in detect- ing imposture will mainly depend upon their science, practical knowledge, and ingenuity. With a tolerable store of each, they will seldom be placed in great difficulty, or be obliged to resort to more painful means of detection than the disease would warrant, were it real. * * [The following concise rules for the detection of feigned and. factitious diseases, from Guy's Forensic Medicine, will prove of essential service to the practitioner (Am. Ed., p. 247) : " 1. Inquire, in all cases, into the existence of motives for deception. Will the suspected person, by imposition, gain anything he desires, or escape anything he dreads ? Is he in a position to profit in any way by deception ? It is neces- sary, in this place, to caution the medical man against con- cluding that a malady is real, because there is no obvious ad- vantage in simulating it. Both men and women are in the hab- it of feigning from other motives than those of gain, such as sympathy ; and occasionally there is so complete an absence of reasonable motive, that we are forced to believe in the existence of a moral insanity displaying itself in this way. " 2. Inquire into the previous history of the patient, and the character which he bears among those who know him best, as his comrades or companions. It often happens that the impostor has been previously noted for dishonesty, and for practices similar to those of which he is suspected. But in other instances, men of the best character, and who have for years filled their situations with credit, have been con- victed of malingering. " 3. In the case of external diseases palpable to the sen- ses, make a minute and careful inspection of the part itself, and examine it by the eye and by the touch. When there is a suspicion of the use of irritating substances, examine the part with care, and search the pockets, boxes, or bed of the suspected party, and, if necessary, isolate him so as to deprive him of the assistance of others, and of his means of deception. Use equal care in inspecting substances al- leged to have been discharged, and examine them, if neces- sary, by the microscope, or by chemical tests. '•4. When some defect or disability not palpable to the senses, but depending entirely upon the assertion of the person himself, as pain, deafness, &c, is assumed, we must endeavour to take him by surprise. In the case of pretended deafness, fur instance, we must try to discover Biblioo. and Refer.—/. B. Syhaticus, InstitutioMed- ica de lis, qui morbum simulant, depreheiidis. Madr., 1593, 4to.—Montaigne, Essays, 1. ii., c. 26.—Guyon, Lefons Di- verges, t. i., p. 118.—Pigrteus, Epit. Med. et Chirurg., p. 508.—P. Zacchia, Questiones Medico-Legates, &c.,3voli. fol. Francf., 1688.—L. Z. Luther. De Morbis Siniulatis et Dissimulalis, 4to. Erf., 1728.—Vogel, De Simulalis_ Mor- bis, et quomodo eos dignoscere liceat, 4to. Goet., 17C9.— De Haen, Ratio Medendi, vol. ii., p. 56.—Fieliz, in Tasch- enchbuch fur Deutsche Wundarzte ad 1786.—Livingston, Edin. Med. Comment., vol. iv., p. 76.—Neumann, De Mor- borum Simulations, 4to. Wittemb., 1788.—Tode. Unter- haltender Arzt., b. iii., p. 7.—Schneider, De Morborum Fic- tione, 4to. Franc, 1794.—Lentin, Beytrage zur Ausiiben- den Arzencywissenschaft. Leips., 1797.—Souville, Rxamen des Infirmites ou Maladies qui peuvent exemplar du Ser- vice Militaire, 1- iv-, v 1, et seq.—Sydenham, Method. Cnrand. Febr., 8vo. Lond., 1666.—Morton, De Febribus, 2 vols., 8vo. Lond., 1692-4.—E. Camerarii, Dis.de Nequitia Feb- rium. Tub., 1632 ; et de Febr. in Genere. Tub., 1693.— /. Floyer, Append, to Preternatural State of Animal Hu- mours, 8vo. Lond., 1696. — F. Hoffmann, De Mechanic^ Febr. Doctrina Hippocratis, 4to. Hal*, 1696.—Stahl, Feb- ris in Genere Historia. Italse, 1701 ; De Febris Rationali Ratione. Hals, 1702; et De Febr. Pathologia in Genere. IIalm o. Lond., 1822. — C F Tacheron, Recherches Anatomico- Pathol. sur la Med. Pratique, vol. ii., 8>o. Paris, 1S23.— F. Barker, and /. Cheyne, Report of the Fever lately ep- idemic in Ireland, dec, 2 vols., Svo. Dub., 1821.—Author, in Quarterly Journ. of Foreign Medicine, vol. ii., p. 433, 1819 and 20, and vol. iii., p. 7-99 ; Lond. Medical Reposi- tory, Jan. 1823, p. 19 ; in Ibid., May, 1822, p. 376 ; in Ibid., June, 1822, p. 483; Ibid., Sept., 1827, p. 236; Lond. Med. and Phys. Joum., Dec, 1820, p. 530 ; Medico-Chirurg. Re- view, vol. viii., p. 368.—/. Annesley, Researches into the Diseases of India and Warm Countries, imp. 4to., vol. n., p. 409.—Cheyne, Report of the Hardwicke Fever Hosp., ar- atively less effect. The means of removing impurities in towns exist partially, and have produced admirable effects; but the most casual observation must convince anyone that our streets were built by persons ignorant as well- of the nature of the atmosphere as of the mortality, which has been proved to exist, and is referrible to causes which, tho»gh invisible, are sufficiently evident." —P. 419.] complicate the disease. The quality of the water has a remarkable influence, both in gen- erating continued fever and in determining its form; putrid water, or water containing de- cayed vegetable or animal matter, generally causing fever of an adynamic, gastric, enteric, or mucous character.—y. Employments and at». ocations may either prevent or favour attacks of fever. Tanners and workmen exposed to the fumes of pitch, tar, chlorine, &c, are rare- ly affected, even when fever is epidemic. Per- sons much exposed to the open air and vicissi- tudes of weather, are most liable to fever of a sthenic or phlogistic kind, and to the pulmona- ry and pleuritic complications.—6. Habits and modes of living are very influential and power- ful determining causes of fever, even in this climate. The influence which full and rich living, and its opposite, poor and unwholesome living, exert upon the state of the disease, has been sufficiently manifested by the epidemics which have prevailed at various times in Ire- land since the commencement of the present century, according as they appeared in the poor and ill-fed, and as they extended to those in easy circumstances. In the former, fever usu- ally assumes the common continued, or the milder adynamic and typhoid forms, often at- tended by the pulmonary complication, or with petechia?, &c, and frequently passing into dys- entery, &c.; in the latter class it is either ac- companied, at an early stage, with high action, or with congestion, and predominant affection of the head, liver, or stomach. In persons liv- ing chiefly upon fish it generally assumes a low and putrid character. Those who are in- temperate, or who have resorted to spirituous liquors on the invasion of the disease, present especial disorder of the brain and digestive mucous surface.—e. Intellectual exertion, mental anxiety, and other inordinate emotions may both occasion a severe fever and aggravate its intensity, even when arising from infection; and, in both cases, a cerebral or typhoid com- plication of a dangerous kind is produced.— f. Previous disorder heightens the severity of the disease, and necessarily determines its pre- dominant features or complications, although sometimes in an indirect manner. Thus, it is common to observe bronchitis previous to, or attending the invasion of fever, followed by a remarkable affection of the brain and of the mucous membrane of the intestines. In this case, the changes effected by respiration on the blood are imperfect; and, consequently, this fluid becomes morbid, disordering first the functions, and ultimately the structure of the digestive mucous surface and brain. XXII. Fever, Typhoid.*—Syn. Adynamic Fe- ver, Asthenic Fever, Febris Asthenica; Febris Contagiosa; Febris Typhoides ; Typhus (J/om rvtboc, stupor, or rvtpu, to smoulder); Fievre Typhoide, Chomel ; Fievre adynamique, F. nerveux, F. ataxique, Fr.; Tifo, Ital.; Der Ty- phus, Nervenfieber, Germ. ; Low Fever, Con- tagious Fever, Infectious Fever. 455. Defin.—After lassitude and general ma- laise, imperfect or suppressed vascular reaction, with depressed vital power, manifested especially in * I use the term Typhoid in the same sense as Cui.LEN and the majority of writers on fever in this country since his time. It is, in this sense, nearly synonymous with most of the names adduced under it. FEVER, TYPHOID—Mild Varieties. 1169 the nervous, vascular, and muscular systems, and giving rise to changes more or less evident in the circulating fluids and soft solids. 456. This fever cannot be said to differ spe- cifically from that last described, although cer- tain varieties of it present very marked distinc- tions. Indeed, the severer forms or complica- tions of synochoid fever very closely approach, or run into certain states of typhoid fever, the chief differences consisting in the more sthenic vascular reaction in the early part of the pe- riod of excitement in the former. Even the milder cases of simple continued fever may gradually assume a perfectly typhoid state in the advanced stage. The distinctions which characterize the following varieties are results of the circumstances already shown (y 43) to de- termine the forms and complications of fevers generally, especially of the constitution and habit of body ; of the previous health and con- dition of vital organs ; of the nature, intensity, and concurrence of the causes of the prevailing epidemic ; of the influences operating after in- fection or during the early stages, and of the treatment and regimen then adopted. i. Mild Typhoid Fever.—Syn. Simple Typhoid Fever ; Nervous Fever; Simple Adynamic Fe- ver ; Regular Typhus; Slow Nervous Fever, Huxham ; Typhus mitior, Cullen ; Febris ner- vosa, Auct. ; Languor Panonicus. 457. A. This form of fever is characterized chiefly by great languor and debility; by gid- diness, dulness, and confusion of intellect; by a soft, feeble, and quick pulse ; and by loss of muscular power, sleeplessness, and low deliri- um. It usually commences with similar pre- monitory symptoms (period of infection, Hart- mann) to those above described. The patient complains of giddiness, lassitude, uneasiness at the epigastrium, of nausea and loss of appe- tite, of alternate chills and flushes, and of pain in the back and limbs, the period of invasion. The chills are often prolonged, or recur for two or three days, but seldom amount to rigour; the skin afterward becomes warm, but seldom very hot: the period of excitement, of irritation (Naumann), of reaction (Hartmann), of inflam- matory irritation (Goeden) ; the pulse frequent, full, soft, or weak ; the countenance dull, pal- lid, and shrunk, or, occasionally, transiently flushed; the head heavy, confused, and giddy; the eye heavy, and devoid of lustre ; and the tongue loaded or covered with a dirty mucus. There are more or less thirst; a desire of cold, acid drink ; sometimes pain at the epigastrium, nausea, and vomiting; or an irregular and re- laxed state of the bowels, and offensive evac- uations. Pain of the head is but little, or not at all complained of, but that of the back and limbs is felt severely; tinnitus aurium is gen- erally present; febrile uneasiness is great, the restlessness constant, and the want of sleep continued. About the third, fourth, or fifth day the head is more affected, and the mind more confused; the respiration is short and quick, and torpor, or coma vigil, is often ob- served ; occasional flushes occur in some ca- ses, while the extremities are cool; the urine is pale, of a whey colour, or like small beer ; occasionally scanty; the bowels are either tor- pid, or relaxed, or irregular ; and deliquium, or faintness, partial sweats, tremours, &c, are complained of on attempt to sit up. Delirium 147 of a low kind, or consisting of a muttering in- coherence, occurs about this time ; generally, at first, during the night, but subsequently re- curring during the day; the eyes become mud- dy, afterward suffused or injected; and the tongue of a darker hue, dry or incrusted. 458. From the 7th to the 9th, 10th, or 11th day, or even later, the delirium degenerates into stupor—the period of predominant narcotism of Naumann, the nervous stage of Hildenbrand, the collapse of Cullen and Hartmann; the pulse becomes small, weak, and very quick, or unequal; the heat of the skin natural, or di- minished, or irregularly distributed ; the hear- ing dull, and tremour, the supine posture, coma, and unconscious evacuations are soon after- ward observed. Petechiae sometimes appear on the trunk, thighs, &c. ; the tongue becomes brown or black, incrusted and fissured, is pro- truded with difficulty, and the gums and lips are covered by a dark sordes. From about the fourteenth day to a much later period, accord- ing to the character of the epidemic, the pecu- liarities of the patient, the severity of the early stages, and the state of internal organs, a fa- vourable change very often occurs in all the symptoms—the stages of crisis and decline, or of recovery (Hartmann)—and is announced by a refreshing sleep, or by a warm and general sweat, or by a gentle diarrhoea, followed by subsidence of delirium, tremour, &c.; by the tongue being moist and clean at its edges, the skin more natural, and the pulse slower ; by returning consciousness, and by the improved appearance of the countenance. If these chan- ges do not take place, or if the sweats are cold and clammy on the extremities ; or if they, or the diarrhoea, be unattended by amelioration of the symptoms, a fatal change should be dread- ed, particularly if profound coma and great deafness, subsultus tendinum, or convulsive or spasmodic movements, difficulty or inability to swallow or to articulate, hiccough, involuntary evacuations, retention of urine, tympanitic ab- domen, sliding down in bed; very rapid, flutter- ing, or intermittent pulse; very black tongue, and a quick, jerking, laboured respiration, or other unfavourable symptoms, appear. 459. B. The symptoms which distinguish this form of fever from the synochoid are, the greater prostration of strength from the com- mencement ; the mental torpor and confusion of ideas ; the long-continued chilliness, gener- ally without rigour or shivering, at its inva- sion ; the moderate increase of temperature afterward, or. its natural grade; the pallid and shrunk countenance, expressive of suffering and debility ; the muddy, lack-lustre eye ; the torpor, giddiness, and absence of pain in the head, passing into stupor with delirium at an early stage ; the quick and small, or the full, open,.and soft pulse, even during the period of excitement;,- the early dryness and dark ap- pearance of the tongue ; the remarkable fcetor of the breath, and of the discharges; the su- pine posture; the dull, dusky, lurid, or dirty hue of the surface; the frequent occurrence of sloughs in the parts pressed upon, or of ery- sipelas, and occasionally of enlargement and inflammation of glands; and the early appear- ance of delirium, with tremour, and other symp- toms, indicating extreme depression of vital power. When any of these phenomena occur 1170 FEVER, TYPHOID—Complications. in synochoid fevers, it is always at a far ad- vanced stage, the synochoid thus merely laps- ing into the typhoid form, owing to various contingent influences, or to predominant af- fections of particular organs. 460. C. Such are the usual progress and characteristic phenomena of simple typhus; but it presents slight modifications, with the activity of reaction in the early stage, with the affection of particular organs or of the skin, and with the character of the prevailing ep- idemic. When the predominant affection is either so evident or so influential as to modify materially the state of disease, certain varie- ties result, which have been described by au- thors as specific or distinct forms of fever, and have been often connected, in too absolute a manner, with the peculiar circumstances in which they were observed, or in which they originated. I shall here notice these varieties, with reference to the circumstances whence their peculiarities seem to proceed, and to the various names imposed upon them, from a de- sire of appearing original, but with the effect of proving inaccurate, or of causing misappre- hension and confusion. 461. ii. Complicated Typhoid or Low Ner- vous Fever.—A. With predominant Affection of the respiratory Organs.—The bronchial surface is the part chiefly affected, and is rather con- gested than inflamed. The pleura is rarely attacked, but the substance of the lungs is sometimes implicated; and it then commonly becomes rapidly infiltrated or condensed, a fa- tal result quickly supervening. This complica- tion is often obscure, or even latent; but it generally admits of detection by auscultation, or by attentive observation alone. The patient sometimes complains of stricture, oppression, or dyspnoea, but very seldom of pain in the chest. The respiration is short and hurried, is attended by the mucous rattle, and with more or less cough. The skin is seldom hot; at a later period it is cool, or even cold in the extremities, and dusky or lurid ; the cheek is tinged with a dark red, and often assumes a livid or purplish hue. The pulse is rapid and weak. The confusion or stupor of an early stage passes quickly into low, incoherent mut- tering and coma. The tongue becomes very dry, black, crusted, and fissured ; it cannot be protruded, and articulation is lost. This state may continue for several days, with uncon- scious evacuations, and all the nervous symp- toms prominently marked ; at last the patient sinks asphyxied, the changes necessary to life ceasing to take place in the blood sent to the lungs.* 462. B. Nervous or Typhoid Fever, with prom- inent Affection of the digestive mucous Surface— the Adynamic Fever of several French writers ; the Dothinenttrie of M. Bretonneau. Many of the observations made respecting this local af- fection in synochoid fever (y 442) apply to its occurrence in typhoid fevers. It is very com- monly observed in large cities, and in circum- stances that occasion the use of water contain- ing animal matter in a state of decay ; and it * rThis complication is extremely common in many parts of the United States, especially during the winter months, and often goes under the name of Pneumonia Typhodes. '& Remarks on « Spotted Fever? under'• Typhotd Fever, with Putro-adynamic Characters," sec. 484.)] commences in a similar manner to the other varieties of typhoid fever. The symptoms that usually attend its progress are, a tumid, tense, hard, or tympanitic state of the abdomen at an early stage of the fever, frequently without pain or even tenderness on pressure ; but with involuntary stools, and unconsciousness of their passage at a later period. The tongue is dry, black, incrusted, and the crust sometimes fissured; but it occasionally is dark red, dry, and devoid of papillae or fur. The stools are often ochrey, and more frequent than natural. Discharges of blood, in greater or less quantity, sometimes accompany them; but the haemor- rhage, and the changes in the mucous surface occasioning it, may occur without much, or even any relaxation of the bowels. 463. C. Typhoid' Fever, with prominent Affec- tion of the cerebrospinal nervous System—the Ataxic of Pinel—is seldom attended by acute pain in the head. But heaviness, stupor, con- fusion, and giddiness are felt severely, and very early in the attack. The eyes are injected, suffused, and devoid of lustre. Delirium ap- pears early, and frequently becomes more vio- lent than in mild typhus, the patient attempt- ing to get up, or out of bed. The scalp is warm or hot, and the extremities are often cool. Insensibility and coma quickly super- vene, and are sometimes attended by spasmodic contractions of the muscles of a limb, or by partial convulsions. Inability to swallow, re- tention of urine, and loss of speech, are occa- sionally observed. Startings of the tendons, relaxation of the sphincters, and failure of the circulation, occur in the last stage, and usher in a fatal termination. This complication is especially characterized by the early appear- ance and the severe form of the symptoms de- pending directly upon the state of the cerebro- spinal nervous system. 464. D. Typhoid or Nervous Fever with severe Affection of several vital Organs—Typhus gra>- vior of Cullen and others—is generally charac- terized by intense disorder of the brain and di- gestive canal, with more or less evident affec- tion of the bronchial surface ; delirium being early, and at first somewhat violent, and soon followed by insensibility, &c. The pulse is quick and weak; the skin is hot, dry, pungent, or harsh, in an early part of the stage of reac- tion, but it generally becomes cool, particularly in the extremities, and often discoloured; res- piration is panting or quick; the tongue dry and black; the abdomen tumid, tender, or tym- panitic ; and the stools are dark, offensive, and passed involuntarily and without consciousness. In this form there is some degree of reaction, expressed most severely in the digestive canal and cerebro-spinal nervous system; but it is characterized by depression of vital power, that is soon increased by the exhaustion consequent upon the reaction induced in this state. 465. The vital organs may, however, be se- verely affected, although excitement be very slightly, or even not at all manifested. Such cases constitute the Congestive Typhus of some modern writers, a form of comparatively rare occurrence, unless accompanied with petechias, and other symptoms indicating serious changes, not merely of vital action, but also of the fluids and soft solids. In this variety the depression of vital power is extreme from the commence- FEVER, TYPHOID—Complications. 1171 ment, and such as prevents the development, and, in some cases, even the least manifesta- tion of excitement. The causes of the disease have given vitality a shock beyond its powers of resistance or of recovery. Muscular power is almost entirely annihilated, and the anxiety at the epigastrium and praecordia is extreme Respiration is oppressed, and the pulse is quick, sometimes irregular, intermittent, or even slow, and always small, weak, and thready. The countenance and eyes at first have an intoxica- ted appearance ; the former being pallid, occa- sionally slightly bloated, or livid and dingy; the latter being vacant or suffused, and, after- ward, injected, ecchymosed, half shut, or open. The skin, at an early stage, is warm or harsh; subsequently it is cool, withered, lurid, and sometimes studded with petechiae or vibices ; the extremities being cool, or even cold, and dingy, or of a leaden hue. The mind is very much confused at the commencement, and soon passes into a state of incoherence, delirious muttering, and coma. The patient is unable to protrude the tongue, owing to deficient power of the muscles of the organ, and seldom com- plains of thirst. The abdomen is tumid or in- flated ; the bowels being relaxed, the stools black and offensive, and, with the urine, passed unconsciously. The progress of the disease is usually rapid, and generally to a fatal termina- tion ; but the premonitory stage may be protract- ed, although severe, the invasion being some- times sudden, and resembling an apopletic seizure. If the powers of life rally, recovery may take place ; but it is tedious, and often at- tended by various consecutive disorders. 466. E. Of other Modifications or peculiar States of Typhoid or Low Nervous Fever.—Vari- ous phenomena besides those already described may accompany this fever, according to the combination and intensity of the causes, the previous health of the patient, and the circum- stances affecting him subsequently to the opera- tion of the exciting agent.—a. When caused by mental distress, despondency, &.C, this fever pre- sents certain peculiarities deserving notice. The patient is dejected, indolent, and incapable of exertion. He loses his appetite and strength ; he cannot rest at night, or his sleep is disturbed and unrefreshing; and he complains of head- ache, and of many of the symptoms of a com- mon cold. He is absent, his mind being con- stantly occupied with the subject of his misery. His countenance assumes an anxious appear- ance, his healthy looks vanish, and his absence of mind often passes into a state of revery. After several days, manifest affection of the brain is observed, with characters varying with the age, strength, condition, and habits of the patient. In the robust, plethoric, and in per- sons addicted to intoxicating liquors, it is sud- den and violent in its accession; the headache and despondency quickly passing into delir- ium of an active and constant kind, the patient calling out, or starting up, and attempting to get out of bed. The pulse is quick, firm, and oppressed or small; sometimes soft or irregu- lar. Muscular power is not so much nor so early reduced as in the other states of the disease, but there is continual jactitation. In the debilitated, the aged, or the ill-fed, the cer- ebral affection is less violent in its attack, and commences more gradually, often attended by red or suffused eyes, or by catarrhal symp- toms, or by diarrhoea; by delirium, tremour, great prostration of strength, hurried breathing, weak, quick pulse, subsultus tendinum, and, sometimes, with a mottled appearance of the surface. In other respects the progress of the disease is nearly the same as the more severe cerebral complications already noticed (y 463), but it much more frequently terminates unfa- vourably. 467. b. In some cases the fever is complica- ted with sore throat; and this symptom is occa- sionally so severe and early as to resemble an attack of cynanche maligna. Indeed, cases not infrequently occur, which fully indicate that the one disease may pass into the other, under favourable circumstances in respect of predis- position and concurrence of the exciting caus- es ; or, in other words, that in young persons, in those predisposed to sore throat, and in cold and humid states of the air, certain of the ex- citing causes of typhoid fever will sometimes occasion a malignant or putrid inflammation of the throat, ushered in and attended by this form of fever; or they will, in such or similar cir- cumstances, produce a low fever, in which in- flammation of the throat is a contingent com- plication, and assumes an asthenic or unfa- vourable character, owing to the depressed state of vital power, and morbid condition of the circulation, in which it occurs. This com- plication is observed either as the most promi- nent local affection, or in conjunction with some other remarkable disorder, especially with the gastric complication. In some instances it is very severe ; the pharynx and upper part of the oesophagus being also more or less af- fected, and deglutition altogether prevented. 468. c. Paralysis may occur, especially in the cerebral state of this fever ; and, in this case, the use of one side of the body is generally lost. If the patient recover from the fever, the func- tions of the paralyzed side are often gradually restored. This complication may take place in those cases which commence with protract- ed or severe premonitory symptoms, against which the patient struggles until he falls down from exhaustion, or is suddenly seized, as in a case of apoplexy; the fever running its course, as after the usual invasion, with chdls, rigours, vomitings, &c. When the disease is developed in this sudden manner, it commonly presents the cerebral character throughout, with delir- ium, passing into coma, &c. In a case, how- ever, of this kind, the cerebral symptoms were subsequently slight, and the disease mild.* In some of the cerebral cases of this fever, the affection of the mind continues for some days, or even weeks, after the bodily functions are restored. Instances may even occur of perma- nent insanity being the consequence. But, in * A young lady went some distance to visit an intimate friend, delirious in fever ; and having gone into the cham- ber, she was sensible of a disagreeable odour upon the cur- tains of the bed being drawn. She soon afterward com- plained of slight nausea, of headache, loss of appetite, and general lassitude. These symptoms continued gradually to increase for six days, during which time she kept about. On the morning of the seventh day she suddenly fell down without sense or motion. I saw her in this state soon af- terward, and, viewing the attack as the result of sudden congestion of the brain, and before I had learned the above particulars, I prescribed a moderate blood-letting and pur- gatives. The functions of the brain soon returned, and the fever ran its course in a mild form, and without delirium or prominent affection of any organ. 1172 FEVER, TYPHOID—Exanthematous Eruptio all such cases, hopes of recovery should be en- tertained until some weeks, or even months, have elapsed from the disappearance of the fever. 469. F. Relapses and Sequela.—a. Relapses are not infrequent after the mild forms of ty- phoid fever, especially when the duration of the disease has been shortened by the treat- ment, or its course materially altered. They are also much more common in one epidemic than in another. In many instances, particu- larly when the procession of the morbid phe- nomena has been interrupted by large deple- tions or drastic purgatives, the symptoms be- come ameliorated for a time, but recur with their previous severity, the recurrence being different from a relapse; b. This fever, espe- cially its gastric and enteric states, may pass, or be converted into a low or typhoid form of dysentery (see that article, v 26, 27), owing to the influence of the same circumstances that usually cause relapses ; especially premature exposure in early convalescence; the use of too much or of improper food; the continued operation of the exciting causes ; a close, im- pure, and infectious air, and suppression of the excretions.—Local affections, particularly inflam- mations, may also appear during convalescence, arising either from the above causes, or from atmospheric vicissitudes; or from whatever may inordinately affect the nervous and vascu- lar systems. In these cases the inflammation is apt to pursue a severe and rapid course, ow- ing to the unfavourable or debilitated state of constitution in which it occurs. Bronchitis, often associated with affection of the substance of the lungs, and inflammation of the mucous surface of the bowels, sometimes with soften- ing and enlargement or ulceration of the mu- cous follicles, are the most common diseases thus contingent on convalescence. Inflamma- tory affections of the stomach or liver may also take place. When the mucous surface of the intestines is the seat of consecutive disorder, the bowels generally are more or less relaxed, and the stools are of an ochrey hue, and offen- sive. In such cases the follicles are especially affected; are often ulcerated ; and although they will generally heal under judicious treat- ment, perforation of the intestines and fatal peritonitis may be the result at a period more or less remote from the disappearance of the fever. 470. G. Of Petechia and Exanthematous Eruptions in Typhoid Fevers.—Nervous or typhoid fevers may occur sporadically or ep- idemically, without any petechial or other erup- tion ; or may be attended by petechia or vibices in their progress, and particularly at an ad- vanced period, or by an exanthematous eruption at an earlier stage; or even by both kinds of cutaneous affection, either successively or al- most coetaneously. For many years, or in successive epidemics, or even in a single ep- idemic, typhoid fever may appear in any one or more of the states just described ; or it may assume either of these forms, associated with one or other, or with both of the affections of the skin just mentioned in a portion of the ca- ses only ; or the affection of the skin may be one of the most unvarying and chief character- istics of an epidemic ; and, of the cases com- posing such an epidemic, some may be of the mild, others of the complicated or severe form; some may evince more or less reaction or ex- citement, others may present depression of the powers of life and congestion as prominent phenomena throughout. The above descrip- tion, although applicable more especially to the occurrence of typhoid fever, independently of any marked affection of the skin, yet does not the less apply to the occasional association of the disease with this affection. Those epidem- ics in which the changes in the skin are very constant phenomena sometimes possess other characters, both in the early and in the ad- vanced stages, that require an especial notice. While these changes—both petechial and exan- thematous—have been considered by Hilden- brand, Naumann, Fodere, Peebles, and other experienced writers as indications of specific kinds of fever, which, in the early stages, may present more or less either of inflammatory ex- citement or of depression of vital power, they have been viewed by many authors merely as occasional occurrences, or as modifications met with only in certain epidemics, and not as char- acteristics of distinct varieties. 471. In trying to solve this question, the same difficulties present themselves that arise in all attempts to arrange the different varie- ties and states of fever in such an order as the more constant phenomena may warrant, and as may conduce to appropriate and successful methods of treatment. If I refer to my own observations in different parts of the Continent, some time after the late war, and in various parts of this country, both before and subse- quently, I shall find, 1st. That petechia and vi- bices were either seldom or rarely seen for several years in some epidemics, excepting in the most severe or malignant cases, or when favoured by a too stimulant treatment and a too heating regimen during the early stages; and that, at other times, they appeared more frequently in the advanced periods of the low- est forms of fever, and even, although much more rarely, towards the termination of syno- choid fever, when antiphlogistic remedies bad been neglected in the stage of excitement. 2d. That this change in some epidemics was a very common or even general symptom, oc- curring in mild as well as in severe cases, al- though presenting very different appearances in each; and that they were sometimes ob- served early in the low states of fever, par- ticularly when caused by unwholesome and de- ficient food, by a foul atmosphere, or by infec- tious miasms. 3d. That they were very frequent- ly connected, especially in the plethoric, in the previously unhealthy, and in persons using much animal food, with evident change of the circulating fluids, with predominant disorder of the digestive organs, with a soft, broad, and open pulse, and with haemorrhages from the intestines, and a tendency to disorganization of the mucous surface of the bowels. 4th. That an exanthematous rash or eruption was ob- served in some epidemics, from the third to the eighth day of the fever, was quite distinct from petechia*, generally appeared earlier, and was, in some cases, either associated with, or suc- ceeded by, petechia; or vibices, or even both. 5th. That this exanthema was of a reddish col- our, varying in deepness, and rarely passing to a dark hue ; that it occurred in cases charac- FEVER, TYPHOID—with Putro-adynamia. 1173 terized by vascular reaction in the early stage, as well as in those of a very low grade : in the mild, in the complicated, and in the severe ; that this eruption was most probably overlooked in many cases where it existed; and that it was very generally confounded with petechiae, owing to its late appearance, or to its colour changing, in a somewhat similar manner to petechiae, with the states of vital power and of the circulating fluids. 6th. That, although the difference between these affections of the skin has been insisted on by Hildenbrand and Nau- mann, it has been too widely drawn by them, and without due reference to the occasional association of both affections. From these facts, therefore, I am induced to come to the conclusions above stated (y 470), and, con- formably with the views of the experienced writers just mentioned, to notice more partic- ularly the states of fever in which these chan- ges in the skin are observed, without consider- ing these states as always constituting distinct species. iii. Typhoid Fever, with Putro-adynamic Characters.—Syn. Putro-adynamic Fever ; Xvvoxoc/iera oynedovoc, Galen ; Synochus Pu- tris, S. cum Putredine, Febris continua Putri- da, Riviere ; F. continens Putrida, Selle ; F. Putrida sanguinea, Vogel; F. colliquativa pu- trefaciens, Quesnoi; F. Hungarica, F. nervo- sa-putrida, F. asthenica, F. contagiosa; F. col- liquativa essentialis, Borsieri; F. Putrida sim- plex, Richter; F. charactere pulrido aut sep- tico, Hildenbrand; F. Petechialis, F. Noso- comialis, F. Castrensis, F. Purpurata maligna, F. Maligna, F. Carceraria, Pestis Bellica; Auct. var. ; F. Continens maligna, Huxham ; Das Faulfieber, Faulige Fieber, Germ. ; Fie- vre grave, F. Maligne, F. Putride, Fr. ; F. Adynamique, Pinel; Febbre Putrida, Ital. ; Morbo Petechiale, Cerri; Febbre Petechiale, Rossi; Febbre epidemica Petechiale, Buff a ; Petechial Typhus, Camp Fever, Jail Fever, Pu- trid Fever, Putrid Malignant Fever, Spotted Fever. 472. Conformably with what I have stated above, I consider this as a variety merely of typhoid fever, its especial characteristic—the appearance of petechia; and vibices—being con- tingent upon certain circumstances and causes tending to contaminate the circulating fluids, and to destroy the tonicity and irritability of contractile tissues, and appearing only as the effect of a series of anterior changes. Although petechia; may occasionally appear in the ad- vanced stages of other fevers, particularly those of the typhoid form, yet in those epi- demics which result from famine, war, un- wholesome food, and from air loaded with pu- trid animal and vegetable matter, or with the emanations proceeding from a number of per- sons shut up in a close atmosphere—causes which are often conjoined—this symptom is very generally, if not constantly observed, and is only one of the indications of the very se- rious changes which have taken place, not only in the blood, but also in the soft and irritable structures of the frame. Infection, either di- rectly or by fomites, is, however, the chief cause, although cold, humidity, fear of the dis- ease, and the other agents just noticed, may either generate the fever de novo, or predispose the system to infection, or aid its operation after exposure to it. Although certain epi- demics evince a putrid or septic character at an early period, and thereby justify the appel- lation generally given to them, yet this char- acter is seldom primary, or otherwise than the consequence of suppression or exhaustion of vital power, the fever commencing in some one of the forms already described. Indeed, there is no variety of fever that may not evince a septic or putrid state, 1st, from the vital de- pression produced by the exciting cause ; 2dly, from exhaustion consequent upon vascular re- action ; 3dly, from the passage of contamina- ting matters into the blood ; and 4thly, from these states conjoined. Hence, when the caus- es are of a contaminating kind, and the influ- ences continuing to operate after infection have a similar tendency, putrid or malignant symp- toms will arise, whether the fever be synochoid, nervous, typhoid, or gastric in its early periods. These fevers are the most prone to the septic character; but others, as remittent, inflamma- tory, and bilious fevers, may also assume it. This particular character may or may not be developed, or may appear at a later or earlier period, owing to the nature and diversity of the causes ; to the condition of the internal functions and of the circulating fluids at the time of attack; to the rigidity or tone, or to the laxity of the softer solids ; to the violence or absence of vascular reaction, and to the early treatment and regimen. 473. A. Petechial, or putro-adynamic fever generally commences with the premonitory and invading symptoms usually observed in other fevers of a low grade. When an epidemic pre- sents changes of a septic or putrid nature, as predominant features, the early stages of the fever vary most remarkably according to the in- tensity of the causes, and the state of the pa- tient. The period which elapses from infection till the manifestation of the disease ranges from a few hours to five or six weeks. It is com- monly some days, but sufficient evidence has been furnished, in the Irish and other epidem- ics, that the longest of these periods may occur. During the time the disease thus takes to form, the usual premonitory symptoms are observed, and increase until chills, horripilations, or rig- ours are felt. In some instances the disease commences insidiously, with or without catarrh- al symptoms, becoming gradually severe and dangerous. In these it is often difficult to as- sign the exact period of attack. Fatal cases most frequently begin in this manner, especial- ly in the plethoric, cachectic, and persons ac- customed to full living. In others, after a pro- tracted and severe premonitory stage, and indis- tinct symptoms of invasion, the fever proceeds with indications of imperfectly developed re- action, and soon assumes a putrid or malignant form. In some cases, rigours and shiverings sufficiently evince the period of attack, and quickly give rise to inordinate reaction, followed by exhaustion and evidence of change in the fluids and soft structures. Among the most constant of the. early symptoms are, dull pains in the head, occiput, back, and limbs ; universal weariness, soreness, and loss of muscular pow- er ; confusion of mind ; pains in the joints and limbs resembling rheumatism; frequent sigh- ing ; nausea or vomiting; and noises in the ears. 1174 FEVER, TYPHOID—with Putro-adynamia. 474. The pulse, when reaction is developed, is full, open, quick, sharp, but soft and easily compressed. Respiration is laborious, suspiri- ous, with oppression or anxiety at the praecor- dia and epigastrium. Burning heat is often felt internally, and on the surface of the trunk. When reaction is either imperfect, or does not take place, the pulse is slow, or not more fre- quent than usual; is weak and compressible, sometimes unequal or intermittent; and the temperature is little or not at all increased, or it is unnatural. The tongue is either loaded and furred, or flabby and covered with a dirty mucus. Thirst is generally urgent. The vas- cular excitement usually continues, in various grades, from six to eight days ; and as it pass- es its acme, or about this period, purplish spots of the size of flea-bites, and of various shades of deepness, appear upon the neck, breast, and insides of the arms and thighs. The pulse becomes more soft and weak ; some- times unequal and small. The tongue is more loaded, and of a darker colour. Thirst is di- minished, or is not complained of; and the ex- cretions present a very morbid appearance, and an offensive odour. To these are added dul- ness of all the senses, or delirium, alternating with stupor, difficulty of articulation, and often also of deglutition, leipothymia, faintness, and tremours. From the eleventh to the seven- teenth day, but frequently earlier, the abdomen becomes tympanitic, if the disease proceeds un- favourably ; the petechiae are of a darker col- our ; vibices or blotches appear on the extrem- ities ; profuse fetid perspirations break out without relief; the posture is constantly su- pine ; parts pressed upon quickly sphacelate; the temperature sinks often below the natural standard ; and the tongue is now black, fissur- ed, or flabby, clean, dark red, or livid. Coma; subsultus tendinum; convulsions; haemorrhage from the bowels; or exudations of a sanious fluid in the evacuations, or from the gums, lips, and nostrils, also take place towards the close. 475. A favourable change most frequently oc- curs from the ninth to the seventeenth day, and is indicated by profound sleep ; by a warm, soft, and moderate perspiration; by turbid urine; by natural stools ; and by a brighter colour, or disappearance of the petechiae. The duration of this fever is seldom longer than twenty-one days, but it may terminate on any intermediate day between the sixth and twenty-fourth. A fatal issue occurs most frequently from the eighth to the fourteenth. Towards the close of an epidemic, the usual course is often departed from; mild cases of short duration, and relaps- es, among these especially, being very com- mon. When mercury has been given so as to affect the mouth, a crisis is prevented, and convalescence is protracted. 476. B. Modifications.—a. Such is the more usual course of the disease, particularly as ob- served in modern times. But it presents various grades of severity, and several modifications and complications. It is in some cases, even in the same epidemic, comparatively mild, yet presenting manifest signs of colliquation, or of a septic tendency, particularly as respects the state of vital power, the circulating fluids, and the appearance of the petechiae. In others, the attack is violent from the commencement, and the symptoms intense, diminution of the vital cohesion of the tissues, and dissolution of the fluids, appearing early and proceeding rapidly. In many, the invasion is gradual, or much less tumultuous, than in these ; the progress is more insidious, and the results are not less dangerous. In both, the body undergoes de- composition soon after death, and the rigidity usually observed post-mortem does not take place. 477. b. When this fever is epidemic, pete- chia? may appear as early as the third, fourth, or fifth day from the attack, in mild as well as in severe cases ; and a white miliary eruption may break out at a late stage, particularly when the perspirations are copious. Yellowness of the skin, or purplish colour of the extremities, or enlargement and inflammation of the glands in the neck or groins, may occur in an advan- ced period. Pimples may also appear on the surface, and may be considered a favourable indication. Although delirium and insensibility generally follow the headache of the early sta- ges, yet the mind may be serene and unaffect- ed throughout, even to the moment of dissolu- tion. In cases which present no distinct sign of invasion, nor of reaction, but proceed insen- sibly to a general colliquation of the fluids and solids, the excretions, both cutaneous and in- testinal, are generally abundant and very offen- sive : the flow even of urine being sometimes excessive. The tongue is occasionally natu- ral, or it is clean and raw-like, or as if streak- ed with blood or with a bloody sanies. An aphthous state of it, and of the lips, is also sometimes remarked. 478. c. In persons who live fully and luxu- riously, particularly if they have passed their thirtieth year, this fever often proceeds in an insidious but fatal manner. Such patients do not complain of pain, or of much uneasiness, although they are remarkably debilitated and depressed. Their manner is somewhat hur- ried, but their intellect is clear. The skin is greasy, and covered with dun petechiae, some- times intermingled with white miliary vesicles; its temperature is low ; the countenance slight- ly suffused ; the eyes glassy; the tongue some- times loaded or crusted, or clean and moist; thirst is often absent, and the pulse but little accelerated. Convulsions are frequent; and a fatal termination often ensues, mostly before the fourteenth day. 479. C. Complications, similar to those al- ready described, may take place in the early stages of this disease.—a. The catarrhal, bron- chial, and pulmonary complications are most common in winter. When the bronchi and lungs are seriously implicated, the respiration is short, hurried, or laboured; cough is fre- quent ; and the sputum is bloody, rusty, or con- sists of a dark, sanious matter, particularly in the latter stages.—b. The association with cer- ebral affection is very frequent, particularly in the strong and plethoric, and in persons whose minds have been much harassed previously to the attack. These latter seldom recover from it. In this state the headache is severe from the commencement; the eyes are injected or suffused; reaction is more or less energetic, and is often attended by epistaxis, which, how- ever, is never critical. Delirium, insensibility, subsultus tendinum, &c, are common phenom- ena in the latter stages of unfavourable cases. FEVER, TYPHOID—with Putro-adynamia—Diagnosis. 1178 —c. The digestive canal and liver are chiefly affected in summer and autumn, the fever as- suming gastric and bilious characters at its commencement, with bilious vomitings, * MR1mMk8 °n thB ,TyPhus Fever of thi« Olimate (Bos- ton Med. Magazine, vol. u., p. 301, 1833).] FEVER, TYPHOID AND TYPHUS—in the United States. 1193 a matter, and, from day to day, converses pleas- antly and cheerfully with him. At length, when he finds that he is truly sick, he wonders that he recovers so slowly ; and unless he has pre- viously known his physician well, so as to have the fullest confidence in him, it is a chance if he do not suspect him of unfaithfulness or in- competence for not curing him more rapidly." " This is the slow fever," says Dr. H.," of which we often hear, and which we occasionally see. It continues for a considerable length of time, three or four weeks, acknowledging little re- spect to remedies of any kind, and in most cases spontaneously but slowly disappears. In some instances, after continuing in this manner for some time, it suddenly assumes more positive symptoms, and hastens to a ter- mination, sometimes favourable, more often fatal. In some rare cases it proceeds slowly to a fatal termination without any great change of character. Such a result is so unfrequent, that we have not often opportunity to ascer- tain the morbid appearances by dissection. The case of the celebrated Dr. Spurzheim appears to have been of this sort; and in that no mor- bid change of structure was discovered on ex- amination after death."* Before proceeding to a more particular description of the continued fever of New-England, we shall give a synop- sis of the symptoms, pathology, and diagnosis of the typhoid fever of Paris, as laid down by Louis, in order that the reader may be able to institute for himself a comparison between them. The mean age of patients attacked by the typhoid affection of Paris was twenty-three years; they were generally persons in good health, and who had resided but a short time in Paris. The predisposing causes were the same as those of other febrile and inflammatory af- fections. The disease came on generally with a chUl of considerable violence, accompanied with trembling, headache, universal feeling of lassitude, anorexy, thirst, some pains in the abdomen, and, in a large majority of cases, li- quid dejections supervened upon these symp- toms during the first twenty-four hours. To the chills succeeded heat ; although they re- curred several days in succession in nearly all the subjects, and generally in the evening; af- terward the skin was constantly more or less hot, and nearly always dry. To these other symptoms succeeded, relating to the cerebral functions, the organs of sense, and the abdominal viscera. The patients com- plained of a peculiar weakness, dizziness, or a dazzling sensation, when rising up and attempt- ing to walk; an inclination to somnolency, so that they readily fell asleep on ceasing conver- sation ; a weakness of memory, and disinclina- tion to intellectual exertion, and an indiffer- ence to danger and to what was passing around them. Sleep was imperfect, unrefreshing, and * [Dr. Spurzheim went on with his lectures for nearly a week after the disease, which proved fatal to him, be- gan ; and it was nearly another week, before either he him- self or his physicians and friends thought it seriously alarming. It went on, however, constantly increasing in severity, but at no time exhibiting any very marked symp- toms, except the delirium which came on a few days before his death, or presenting any prominent object for the ap- plication of remedies, and he died at the end of about four weeks. On dissection no morbid appearances were discov- ered which would serve to explain the pathological charac- ters of the disease.] 150 disturbed with dreams. Delirium frequently accompanied the somnolency, but rarely prece- ded it; sometimes it commenced from two to six days after it; was slight, and only during the night; or more marked and constantly pres- ent ; occasionally it was so violent as to make it necessary to use corporeal restraint, and, like somnolency, it generally continued until death, except where the disease ran a long time before proving fatal. Tinnitus aurium was a frequent symptom, and sometimes connected with deafness, which began later than the oth- er symptoms, and often became total. The eyes were injected, and somewhat smarting ; sometimes of a uniform rose tint, though rare- ly so at the commencement; and one patient had strabismus ; many suffered from epistaxis, from which they experienced no relief. The greater number had an eruption of rose-colour- ed lenticular spots on the surface of the body, more or less thickly clustered together ; and these eruptions generally made their appear- ance about the tenth day of the disease, never before the seventh day, and they varied no less in duration than abundance. Sudamina were frequently connected with them. The abdomen was meteorized (tympanitic), and rarely preserved its natural size and form to the end of the disease ; in some this meteor- ism was slight, in others more marked, so that the abdomen projected beyond the line of the chest. As these characteristic symptoms be- came developed, diarrhoea increased ; if much delirium was present, the dejections were in- voluntary, and often tinged with blood. The tongue, in a large number of cases, presented no unusual appearance, but in general it was gluey or dry, sometimes ruddy or red, at times coat- ed, at others not so, crusted or otherwise, in certain patients blackish, in others more or less thick. It was protruded with difficulty, and with a tremulous motion ; deglutition difficult; the back part of the mouth more or less infla- med. Nausea and pain at the epigastrium were not infrequent symptoms, and vomiting also, in the latter stages of the disease. The debility daily increased, the patients stood erect with difficulty, and trembling; walked as if in- toxicated ; at length took to the bed, in which they lay in the same position, ordinarily upon the back, and were moved about like inanimate substances. Soon the skin over the sacrum became red, excoriated, and gangrenous ; blis- tered surfaces were covered with pus of an of- fensive odour and had a livid colour, and ul- cerations of the skin, to a greater or less ex- tent, took place. The skin was generally very hot and dry ; chills were occasionally felt; the pulse was much accelerated, usually above 100 per minute, and small, feeble, contracted, and irregular. In a few it preserved a certain de- gree of fulness till death. In a majority of cases there was more or less cough present, to- gether with a sonorous rale throughout the chest. Towards the close of the disease, the crepitous murmur was often heard over a cir- cumscribed portion of the thoracic surface. Remarkable changes took place in the coun- tenance in the course of the disease. At first, in a large number, the face was purplish and bloated, which gradually subsided, till there was a total want of expression; at length it became sunken, or there was stupor, or abso- 1194 FEVER, TYPHOID AND TYPHUS—in the United States—Symptoms. lute indifference, or the patient appeared ab- sorbed in a profound revery, in violent excite- ment, or had simply a wildness of look, accord- ing to the kind of delirium present. The lips and eyelids were sometimes spasmodically con- tracted, or the muscles of the jaws, giving an expression of suffering and pain ; these spasms were sometimes of long continuance, so that there was subsultus tendinum, or spasmodic motions of the upper extremities, or permanent contraction of the same parts. Death often occurred from perforation of the small intestine; sometimes it took place while the patient was in delirium, or in a kind of calm, the patients having lost their consciousness but a few hours only, and occasionally it took place suddenly. Such were the phenomena in most cases of the severe typhoid fever, of which M. Louis has given a history. In many patients there was merely present febrile excitement, with heat of skin, thirst, slight somnolency, and gid- diness, with loss of appetite, and moderate de- pression of strength ; diarrhoea and pains in the abdomen were absent, so that the seat of the disease could not easily be indicated. These were what Louis calls latent cases of the dis- ease, which, however, often terminated fatally from perforation of the intestine. The symp- toms were extremely varied in different cases, the diarrhoea and meteorism being in some ca- ses the most prominent symptoms ; in others, the prostration, delirium, and spasmodic mo- tions giving the disease the characters, either of putrid ataxic fever, or an inflammatory one, in which the pulse was full, and the surface florid and hot. The duration of the disease varied from eight to forty days. On dissection, more or less serious lesions of the elliptical patches (Peyer's glands) of the small intestine were always found ; and these were more serious, according to the proximity of the patches to the ileo-ccecal valve, present- ing remarkable differences according to the du- ration of the disease, and accompanied by anal- ogous changes of the corresponding mesenteric glands. The others were frequently diseased, but their lesions were not constant, and differ- ed in some respects only from those which are observed in those who die of other acute dis- eases.* Whatever opinion may exist in the profession as to the practical benefits that are to result from attempts to identify forms of fever exist- ing here with those prevailing in other coun- tries, no one can deny the importance of be- coming accurately acquainted with their phe- nomena, their nature, seat, and anatomical char- acters. Diagnosis.—The diagnostic symptoms of the affection, according to M. Louis, are epistaxis, rose-coloured lenticular spots on the skin, su- damina (when large and numerous), meteorism, a blackish and thickly-coated tongue, drowsi- ness, stupor, extreme debility, when not pro- portionate to the other symptoms, eschars upon the sacrum, ulceration of the surface where blisters have been applied, spasmodic move- * [" Anatomical, Pathological, and Therapeutic Research- es upon the Disease known under the name of Gastro-Enter- ite, Putrid, Adynamic, Ataxic, or Typhoid Fever, compa- red with the most common acute Diseases," by P. Ch. A. Louis, Translated from the original French by Henry J. Bowditch, M.D., 2 vols. 8vo. Boston, 1836.] ments or permanent contractions of the mus- cles of the different parts of the body ; " phe- nomena," says M. L., "which are very rarely observed, or which do not occur in other acute affections, or which exist in a moderate degree when observed at all. When more or less of these symptoms exist in the same subject, we cannot doubt that he is attacked with the ty- phoid affection; that the elliptical patches of the ileum are the seat of the lesion which has been described ; for if each one of these symp- toms is observed occasionally during the course of other acute affections, such is not the fact with a combination of them. There is no dif- ficulty in the diagnosis when all these symp- toms coexist, but the most important of them sometimes fail to appear, and a majority exist at a certain period only of the affection" (loc. cit.). Dr. E. Bartlett* remarks that " it is hardly possible to confound typhoid fever with any other affection. There is no other, in any considerable degree, resembling it. Chills, more or less severe, repeated or not, accom- panied with, or immediately followed by head- ache, and pains in the back and limbs; these pains subsiding and disappearing in the course of a few days ; thirst; heat of skin ; accelera- tion of the pulse, with an evening exacerbation; entire loss of appetite; great muscular debility; dulness and confusion of the intellect, passing gradually into delirium ; restlessness ; vigi- lance or somnolence ; twitching of the tendons, or picking at imaginary objects ; occasional epistaxis ; ringing or buzzing in the ears; the appearance of a scattered, rose-coloured erup- tion, principally upon the skin of the chest or abdomen, during the second week ; a dry, glu- tinous, cracked, red, brown, or blackish tongue, protruded with difficulty, and trembling; dark, thick sordes upon the teeth ; diarrhoea, the stools thin, watery, and dark, or yellowish, sometimes consisting of blood; tympanitic dis- tention of the abdomen ; dulness on percussion over the spleen, and gurgling upon pressure upon the right iliac region; with a dry, sibi- lant, or sonorous rhonchus over the chest: these symptoms, coming on without any obvi- ous cause, occurring in a person under forty years of age, and referable to no local disease; more or less regularly and successively devel- oped ; increasing in severity, and terminating in death at an indefinite period after the eighth day, or gradually subsiding and disappearing, one after another, and giving way to convales- cence at an indefinite period after the fifteenth or twentieth day, mark, most clearly and un- equivocally, a disease wholly unlike any other. These symptoms are sometimes, during the progress of the disease, and in various degrees of relative severity, all of them present; and in these cases, at any rate, there is no possi- bility of mistaking typhoid fever for any other disease. The diagnosis, independent of the evidence to be derived from the lesions found after death in the fatal cases, is easily and cer- tainly made."—(Loc. cit.) Symptoms.—Typhoid fever generally makes its attack in a very insidious manner, more so, perhaps, than any other acute disease what- ever. The patient complains of mental and *. t".™" Hist°p>< Diagnosis, and Treatment of Typhoid 8vl 0/Phfl im]™ ' by ELISHA Baktlett, M.D. FEVER, TYPHOID AND TYPHUS—in the United States—Symptoms. 1195 bodily languor, of more or less debility, disin- clination to motion, pain in the head, back, or Limbs, and a sense of general soreness and fa- tigue. Its progress has been well described in the above extracts by Drs. Hale and Bart- lett. Dr. Nathan Smith, also, says that " the disease attacks in such a gradual manner that we hardly know on what day to fix its com- mencement ;"* and Dr. James Jackson re- marks that " there is more difficulty, perhaps, in ascertaining the commencement in cases of typhoid fever than in any other acute diseas- es."! Chomel, however, states that the access was sudden in seventy-three cases out of one hundred and twelve cases, and in the others there were obscure premonitory symptoms. The first symptom may be a chill, attended by debility and headache, and followed by heat and thirst; or it may be a severe griping pain in the bowels, with tenderness on pressure. A severe and fatal case, which we lately saw in consultation, came on with a severe chill after riding a considerable distance in a snow- storm, the patient having suffered much from the cold. Diarrhoea was, in this case, a very early symptom. Of thirty-three fatal cases cited by Louis, thirty-one had chills; and of forty-five grave cases that recovered, all had chills but three ; and of thirty-one mild cases, there were chills in twenty-four ; and generally they occurred in the commencement of the disease. Tiie chill, or rigour, is followed by increased heat of skin, varying much in degree; sometimes moderate, and diffused pretty equal- ly over the whole body ; at others intense, and unequally distributed. " Sometimes," says Dr. N. Smith, " the head and trunk will be exces- sively hot, while the extremities are cooler than natural; at others, the extremities will be preternaturally hot, when the body is but mod- erately so. One cheek will often appear of a deep red colour, and be very hot, while the other remains pale and cool: as its colour and heat subside, they seem to cross over and af- fect the opposite cheek in the same manner. This colour and heat usually extend so far as to include the ear of the affected side."—(Loc. cit.) The skin is also variously affected in regard to heat and moisture; being sometimes dry through the whole course of the disease, at others covered with profuse sweats, which may be partial or general, and often of an acrid smell. The body, also, emits a peculiar odour, which is of a musty, cadaverous kind, and char- acteristic of this affection. The pulse ranges from 70 to 140 in a minute ; its frequency being proportioned to the severity of the dis- ease. Of cases reported by Dr. Jackson that recovered, the average least frequent pulse was 74, and the average most frequent pulse 102; while, in fatal cases, the average least frequent pulse was 91, and the average most frequent pulse was 129. Among the fatal cases in the males, the average least frequent pulse was 85, the average most frequent pulse was 124; while among the fatal cases in the females, the average least frequent pulse was 106, and the average most frequent pulse was 138: show- ing that the pulse is considerably more fre- * [" A Practical Essay on Typhus Fever," by Nathan Smith, M.D.] t [Report on the Typhoid Fever, by James Jackson, M.D.] quent in female than in male patients. The respiration is modified as in other grave dis- eases, where there is a morbid condition of the brain ; and Nathan Smith alludes thus to a pe- culiarity in the breathing: " After the patient has been some time sick, if the disease proves severe, there is a peculiar whistling sound pro- duced when he breathes through the nose ; and when asleep, or lying in a state of coma, the mouth is generally kept open, and the breathing has somewhat of a stertorous sound." Dyspnoea is not unfrequent, where there is much abdominal tympanitis. There is always more or less cough present after the fifth day, and the sputa are small in quantity, sometimes tenacious and colourless, sometimes bloody, and indicating pneumonitis. There is also gener- ally present a dry, sonorous, or sibilant rhon- chus, which is very characteristic of the dis- ease ; and this, in many cases, is loud, and heard over the whole chest. Occasionally, there is a humid or moist rhonchus. Pain in the head is a very constant symptom ; so that out of 87 cases in which the patients recovered, Louis mentions that there was headache in all but three. It generally is one of the first symp- toms, and is of a dull, heavy, or throbbing character, first felt in the morning; sometimes intense and acute, occasioning great suffering. Most frequently it occupies the forehead and temples, but often the whole head, and in se- vere cases its duration is from eight to ten days. The headache is often attended with severe pains in the back and limbs. The state of the mind has already been alluded to. Men- tal languor, indifference, irritability, forgetful- ness, listlessness, or impatience, merging grad- ually into delirium or stupor, are all met with, and the delirium is severe in proportion to the danger. Statistics prove that this symptom is present in at least 38 cases out of 46 (Louis). Dr. Bartlett states that he has seen the dis- ease prove fatal in the second week without any delirium; we have never met, however, with such a case, although we have seen much of the disease in New-England, as well as in this state. In many instances it is mild and temporary; but if the patient be carefully watched, especially during the night, or during the febrile paroxysm, it will be found to exist more or less strongly marked. In fatal cases, it generally continues till the patient sinks into coma, or perishes. It is generally low and muttering ; the patient appears confused or in- toxicated, picks at his bed-clothes, is restless, and in constant motion; or the delirium may be playful and childish, or distinctly monoma- niacal. In most cases, by exciting the atten- tion, the patient may be roused from his state of incoherency, and even from that of coma; although he relapses into it immediately when the attention is withdrawn. Dr. N. Smith al- ludes to this circumstance, and also states that the patient, on recovery, forgets everything that occurred during his sickness. Dr. S. also relates instances where the moral principle seemed to have been affected after recovery; so that persons acquired a propensity to steal, or com- mit other offences. Louis states that, of 300 cases of typhoid fever, there was but a single one where there remained any morbid condi- tion of the mind after convalescence. The countenance is heavy and stupid, dull, listless, 1196 FEVER, TYPHOID AND TYPHUS—in the United States—Symptoms. and vacant, expressive of languor, and total indifference and apathy of mind. Where the pain is severe, the expression of features is one of anxiety and distress ; in mild cases there is no particular change, but a want of animation and cheerfulness. Somnolence, or drowsiness and stupor, is a symptom rarely absent in the typhoid affection; preceding, or alternating with delirium; persisting, in fatal cases, till it is lost in coma, and appearing ear- ly in proportion to the intensity of* the disease. Of cases treated in the Massachusetts General Hospital, it occurred in one case in 381 of those that died, and one in 7-25 of those that recovered (Jackson). Louis found it present in nine tenths of his fatal cases, and in one half of those that recovered. Vigilance, or prolonged and obstinate watchfulness, inter- rupted occasionally by a transient slumber, and often associated with delirium, is also a fre- quent symptom in typhoid fever. The hear- ing we have generally found impaired from an early period of the disease ; and the patient often imagines that he hears sounds and voices that do not exist. Tinitus aurium, or ringing in the ears, is a frequent symptom, especially in the early and middle periods of the disease. The vision is seldom much affected till near the close of life, although it sometimes is false, double, or distorted; and the eyes present a peculiarly heavy, languid appearance, watery, or red from an injection of the conjunctival vessels. The secretions of the eye are gener- ally viscid (causing the eyelids to adhere), ac- cumulate in the angles, dry, and often put on the appearance of scabs. The sensibility to light is sometimes much increased. The sense of taste is dull and perverted, so that nauseous medicines are swallowed without repugnance. The voluntary motions are unsteady ; the tongue is tremulous when protruded, and there is often more or less subsultus tendinum. Dr. Jackson found this symptom present in 1 of 3-36 fatal cases and in 1 of 10 03 of those that recovered. The muscles of the face are some- times spasmodically affected, producing con- traction ; or the diaphragm is affected in a sim- ilar manner, causing hiccough. Prostration of the muscular strength is an early and strongly- marked symptom of typhoid fever. The voice is altered from the beginning ; early in the dis- ease it is usually rather plaintive and small, but as it advances, and more particularly in bad cases, it becomes guttural, and at last tru- ly sepulchral. The patient lies on the back, and is constantly inclined to slide down towards the foot of the bed (Smith). An increase of muscular strength, shown by turning upon the side, is a highly favourable symptom, and often indicates the commencement of convalescence. The abdominal symptoms, or those indicative of an affection of the digestive organs, are per- haps more characteristic of typhoid fever than those already mentioned, and they especially serve to distinguish this form of disease from typhus fever. As we observed the disease in Connecticut, the tongue was generally covered with a whi- tish fur in the commencement, which became yellowish as the disease progressed, and grad- ually changed to a brown, or even black col- our in some instances, when it would crack and peel off, leaving the tongue smooth, dry, and very red. The same process would be re- peated the second, and even the third time, in the course of the disease ; a circumstance also mentioned by Nathan Smith (loc. cit.). In some cases, as Dr. Bartlett has observed, the tongue was but slightly altered in appearance, covered perhaps with a light fur, somewhat inclined to dryness, or to a yellowish cast; or it may be smooth, moderately red, and moist with a te- nacious, adhesive matter. Sometimes a brown stripe runs through the middle of the tongue; or it becomes red at its tip and edges: or it is coated with a whitish, aphthous exudation or ulceration, which involves the fauces and the mucous membrane of the mouth generally; or the whole tongue becomes swollen, painful, and tender. The dryness of the mouth and tongue, owing to the deficiency of salivary secretion, occasions a difficulty of protruding the tongue, of swallowing, and other disagreeable sensations; and the lips and teeth are covered with a dark, tenacious sordes, very adhesive. A thick, tough mucus is secreted in the fauces, which is often thrown off in large quantities. The appetite is wholly gone, as well as the power of digesting food; and in their place succeed nausea and vomiting, the matters thrown up consisting of vitiated mucus, or mucus mixed with bile of an unhealthy colour and consistence. Diarrhoea is a frequent symptom in typhoid fever. In all Louis's fatal cases it was present, with the ex- ception of 3 ; and in 40 fatal cases, it was pres- ent on the first day of the disease in 22. Dr. Jackson states that it occurred in more than half his cases, or 1 in i-77; and of these cases, a much larger proportion died than of those in which this symptom was not present. In mild cases, it is often absent, and makes its appear- ance at a later period in the disease. Dr. Smith observes that " the latter stage of all severe ca- ses is attended with diarrhoea." According to Dr. Hale, diarrhoea is a more frequent symptom in the typhoid fever of Paris than in that of New-England ; and this opinion is confirmed by the Report of Dr. Jackson The stools are liquid, turbid, or of a yellowish or dark-brown colour, like new cider; of a fetid, offensive smell; and sometimes contain blood, rarely any mucus. Dr. Smith has truly re- marked that the danger of the disease is in proportion to the violence of the diarrhoea; that when the patient has not more than four or five liquid stools in twenty-four hours it is not alarming, as it does not weaken him much; but that if they exceed that number, serious consequences may be apprehended. He adds that he never lost a patient whose bowels con- tinued constipated through the whole course of the disease, nor ever knew a fatal case of it unattended by diarrhoea. Abdominal pains, generally proportioned in severity and frequency to the diarrhoea, are characteristic symptoms ; and with them, me- teorism, or a tympanitic condition, is a common phenomenon. According to our observation, this is a later symptom in the disease than the others above mentioned ; although Dr. Hal« remarks that he met with it most frequently in the beginning of the attack. The peristaltic action, as Dr. Smith observes, is sometimes en- tirely suspended, and flatus rarely passes per anum. Emaciation generally goes on gradu- ally, and often becomes extreme where the dis- FEVER, TYPHOID AND TYPHUS—in the United States—Anatomical Lesions. 1197 ease is protracted ; but it is not generally very obvious before the end of the second week. The urine, at the commencement, is not high- coloured, nor does it deposite a sediment; the quantity is somewhat greater than natural, and it often foams, on being voided into a vessel, like new beer. As the disease advances, it be- comes more highly coloured, and lets fall an abundant sediment towards the close. Epi- staxis is a common symptom; and lenticular, rose-coloured spots are so frequently observed on the skin as to have received the name of typhoid eruption. Dr. Bartlett describes it as a small spot, not a pimple, slightly elevated above the surrounding skin, not always sensi- ble to the touch ; about as large in circumfer- ence, on an average, as the head of a pin, and of a bright red or rose colour; disappearing on pressure, and as suddenly returning when the pressure is removed. This eruption is believ- ed by some to be almost an invariable accom- paniment of typhoid fever; and yet Louis found it in 26 out of 36 fatal cases only ; Dr. Jackson observed it in but two thirds of his patients in the Massachusetts General Hospital; and Dr. Hale states that he met with it in 177 out of 197 cases ; and he believes the rose-coloured spots to be a constant attendant upon the dis- ease. Sudamina, or transparent vesicles, were noticed by Dr. H. in 75 cases ; and they were present in two thirds of Louis's cases. They generally occur late in the disease, being sel- dom seen before the twelfth day, and disap- pearing after a few days. Anatomical Lesions.—These have been de- tailed at great length by Louis, Chomel, Hale, and Bartlett. The most striking are those connected with Peyer's glands. There is a diminution in the natural proportion of the fibrin of the blood, and the cavities of the heart often contain whitish fibrinous coagula (Andral and Gavaret). Blood drawn from the veins during life rarely exhibits the buffy coat; and when present, it is generally soft, gelatinous, or infiltrated, and of a grayish or greenish colour. Dr. Hale has recorded the results of 33 dissections after death from ty- phoid fever,* a synopsis of which we present (from the Am. Journ. Med. Sciences, vol. xxv., p. 397), as the fullest history of the pathologi- cal changes in this disease hitherto given in our country : " The head was examined in fourteen. There was some effusion of serum in the arachnoid, or pia mater, in ten cases ; an increase of bloody points in the cerebrum, with other marks of fulness of the blood-vessels, in four; glands of Pacchioni enlarged in two ; and three were healthy. These appearances are not peculiar to this disease, but are found quite as often in many others. " The passages in the neck were examined only in seven cases. Ulceration of the epiglot- tis was observed in one case, and ulceration of the tongue in two. In the remaining four all the passages were healthy. " The state of the lungs was noticed in thir- ty-one cases. In eighteen they, as well as the * [Remarks on the Pathology of the Typhoid Fever of New-England, as exhibited in its Physical Signs and Ana- tomical Appearances, by Enoch Hale, M.D., Attending Physician to the Massachusetts General Hospital. Boston, 1839, 8vo, p. 77.] pleura, were healthy; in three there was effu- sion into the cavity of the pleura ; in eight, he- patization, more or less, of the lungs, some- times in one or two small masses ; at others extensive; and, in one or two cases, in both lungs ; in two the lungs were engorged with blood ; in one infiltrated with serum; and in two there was more or less emphysema. The heart was examined in twenty-eight cases. In three there was somewhat more than the usu- al quantity of serum in the pericardium. The structure of the heart was healthy in all, ex- cept rather flaccid in two or three. In about the same number there was a little thickening of the mitral and semilunar valves. " In the abdomen the morbid changes were more important. The peritoneum was some- times found extensively and highly inflamed. In the greater number it was not particularly affected. The condition of the stomach is no- ted in thirty-two cases. In seventeen it was nearly or quite healthy; in six there were ul- cerations in the mucous membrane, in one case perforating it, in the remaining five small and superficial; in five the mucous membrane was softened more or less extensively, but in no case thickened ; and in five it was somewhat mamelonated. " In the small intestines, the mucous mem- brane generally was healthy, except that it was often of a deep-red colour in the lower part of the ileum, and sometimes a little softened. " Dr. Hale next speaks of the appearance of Peyer's glands in their natural state, and de- scribes the changes produced by disease. He notices four classes of appearances, according to the stage of disease in which the patient has died. When this occurs early, there is a well- defined, uniform thickening of the altered patch, commonly of a light-red colour, over the whole surface, sometimes surrounded by a deeper-red line, the intervening surface being softened, and studded with numerous minute, white, opaque points. Twenty or more of these patch- ed are often discovered. They are most nu- merous at the lower extremity of the small in- testines, and the disease is always more advan- ced in those near the coecum than at a greater distance. " In a somewhat later stage, ulcerations are observed in some of the diseased patches. They are of different sizes, sometimes quite small, at others occupying nearly the whole patch. They are situated in the submucous cellular coat of the intestine, laying bare, and sometimes de- stroying the muscular coat; in some instances they penetrate the peritoneal coat. In these there is the same evidence of greater progress in the patches near the coecum. Not unfre- quently there is a particularly large and deep ulcer almost or quite in the ccecal valve, while some elevated patches higher up are free from ulceration. " In cases where the patient has relapsed after a temporary convalescence, when he dies of pneumonia, or other cause, after a long strug- gle, the ulcerations of Peyer's glands are found cicatrized. The margin is of a bluish or gray- ish colour, and sometimes the colour is diffu- sed over the whole patch, and a delicate mu- cous membrane is found extended over the cicatrized surface. The cicatrization is found farther advanced near the termination of the f 1198 FEVER, TYPHOID AND TYPHUS—in the United States—Anatomical Lesions. ileum than above, showing, as in the other ca- ses, that the affection of the glands began in this part. " The fourth class of appearances are formed by perforation of the intestine. This is of va- rious depths; sometimes it takes place in the peritoneal coat, and the contents of the intes- tine are poured into the peritoneal cavity, pro- ducing violent inflammation and speedy death. This termination is not confined to cases that have been previously remarkably severe. It often occurs in those, at first, of a mild charac- ter. The patient has been walking about the room, with a confidence of a speedy recov- ery, when he has been suddenly seized with excruciating pain in the abdomen, and died in a few hours. There are no intimations by which the danger of this occurrence can be foreseen. " In one or more of these modifications, an affection of Peyer's glands is found in every case of typhoid fever. Out of the thirty-three cases, nine presented only the first stage of this affection ; thickening, softening, and a red surface. In eighteen, while some of the dis- eased patches were in this stage, others, near the lower extremity of the intestine, had pass- ed into ulceration, the ulcers varying in num- ber from two or three to twenty or more. In three, some of the ulcers near the coecum had been cicatrized ; and in three the intestine was perforated. The perforation was, in no in- stance, in the ulcer nearest the ccecal valve, and in one case it was at a distance of four inches. The periods when these changes oc- cur are various. In two, ulcerations were found before the twentieth day ; while in one the dis- ease had continued for months, and there were but three ulcers, and no cicatrization. " The solitary glands in the small intestines were enlarged in fifteen cases. In eleven they were not visible, and in seventeen they are not mentioned in the record ; probably they were not enlarged. The affection of these glands was chiefly found in the lower portion of the intestine. In the large intestines the solitary glands were found enlarged in five cases , healthy in seven ; and in six they are not mentioned. In two the mucous membrane was softened. In seventeen, ulcers, quite nu- merous, were found in the coecum, or first part of the colon. These ulcerations were not large, like many of those in Peyer's glands, but small and distinct. In one case, in which the immediate cause of death was hcemorrhage from the bowels, a firm coagulum of blood was found hanging from an ulcer in the coecum, showing the source of the haemorrhage. In this, and many other cases of haemorrhage, both the large and small intestines contained a considerable quantity of blood. " The condition of the mesenteric glands corresponded to the state of disease of the in- testinal canal. Those glands which belonged to the healthy portion of the intestine were healthy, while those of the diseased part were enlarged, red, and infiltrated. At later stages they were found softened, and sometimes sup- purated. " The liver was examined in twenty-seven cases. Its structure was healthy in fourteen ; more or less soft and friable in ten ; hard in one ; congested in one; and in one the serous coat of the left lobe was highly inflamed, and covered with a coating of lymph. " The spleen was large in twenty-one ca- ses. In some it was enlarged to twice or thrice the natural size, and then commonly soft in its internal texture, breaking down by pressure into a sort of thick, dark-red fluid. In seven cases it was of its natural size ; in two small; in two its condition was not noted. " Dr. Hale gives an abridged history of four cases, one in illustration of each of the forms in which he has described Peyer's glands as affected. " He next proceeds to inquire as to what ex- tent the same morbid appearances are to be found in other acute diseases. For this pur- pose he examined the records of 159 cases of acute diseases at the hospital. Of these, eigh- teen were fatal, and fifteen were examined af- ter death. Sufficient data were not found for a comparison of the state of the head, lungs, and heart. The stomach was noted as healthy, or nearly so, in seven cases ; the mucous mem- brane was mamelonated in three ; and in five its condition was not particularly described. " The state of Peyer's glands is referred to in eleven cases, in all of which they were healthy. In two the organs of the abdomen are declared healthy; in two no reference is made to them. Dr. Hale mentions six other cases of similar diseases, in all of which they were healthy. He states that there is no other disease except typhoid fever in which these glands have been found diseased in the adult. In phthisis they are the seat of ulceration and of tubercular de- posites, but the appearances do not resemble the thickening and ulceration of typhoid fever. " In teething children the glands are affected in precisely the same manner as in typhoid fe- ver. Dr. Hale has seen six cases in his prac- tice of children who have died during teething, in which the glands were thus affected. " In four of the fifteen cases of acute disease before referred to the solitary glands of the small intestines are noticed as enlarged; and in one-they were ulcerated in the coecum. In the remaining eleven they are not mentioned; probably because no disease was observed in them. The spleen was mentioned in three ca- ses ; in four it was small, and in three of nat- ural size, or healthy. In one case where it was large, and in two where it was small, its texture was soft. The liver was examined in all the fifteen cases. It was healthy in seven, and somewhat soft or friable in eight. In three it was large, in three small, and in nine its size was not noticed as unnatural. The other or- gans furnished no points of comparison to de- mand attention. " From this statement, it appears that the spleen, stomach, and liver were affected in a less proportion of cases than occurred in the observations of Louis. Dr. Hale, however, considers the only essential difference between the fever of Paris and New-England to be in the greater frequency of diarrhoea in the latter. This difference is, however, the same in other acute diseases." The appearances, on dissection, as given by Dr. Hale, correspond very closely with those recorded by Louis and Chomel, as witnessed in the typhoid fever of Paris. The anatomical characters are various and complex, corre- FEVER, TYPHOID AND TYPHUS—in the United States, Lesions, etc 1199 sponding in this respect to its symptomatology; most of them are doubtless accidental, and it is difficult to determine, with any degree of cer- tainty, what relation the most constant and es- sential of them bear to the disease itself. The affection of Peyer's glands is undoubt- edly the most important characteristic of the disease ; but we cannot regard this as primary, and the cause of the other morbid phenomena. It may be one of the earliest pathological chan- ges that takes place in the solids; but it re- mains to be proved that it is invariably pres- ent, or that, when present, it gives rise to the existing symptoms. On this point some of our writers have drawn hasty conclusions from a too limited array of facts. That typhoid fever is not a gastro-enterite, is very certain; nei- ther is it a dothinenterite ; for its severity bears no constant relation to the intensity of the lo- cal disease. The phenomena of the disease cannot be satisfactorily explained from the lo- cal lesions of the intestinal canal. In short, we hold, with Bartlett, that " it is much more philosophical and satisfactory, much more in accordance with what is seen in many other diseases, to regard the lesion of the elliptical plates, not as the local cause of all the other appreciable phenomena of typhoid fever, but as constituting one of the pathological elements in a very obscure and complex disease; all which elements—and this quite as much as the others — are themselves the result of some morbific agent, or influence, or process, the na- ture, sources, and operation of which are wholly unknown to us."* Dr. B. supposes that the lesion of the elliptical plates bears the same relation to typhoid fever as that which their several characteristic eruptions bear to mea- sles, scarlatina, and smallpox; in none of which can we regard the cutaneous eruptions as the causes of the symptoms and of the oth- er various phenomena which go to make up the several diseases themselves. The causes of typhoid fever are as yet but imperfectly un- derstood ; age has a powerful influence in its production, as, in 291 cases occurring in the Massachusetts General Hospital, and analyzed by Dr. Jackson, the average age was about 22 years and a third; of 138 cases reported by Louis, 59 were between the ages of 18 and 30 ; and of 117 cases mentioned by Chomel, 91 were between the ages of 18 and 30 years. Louis and Chomel, also, have shown that recen- cy of residence in a place, especially in cities, has an important influence in predisposing to the disease. Typhoid fever is regarded by some, and perhaps a majority of our practising physicians, as decidedly contagious. Dr. Na- than Smith, a capital observer, considered the disease to be as contagious as smallpox or measles, and gives instances where it was ap- parently propagated from one individual to an- other. Louis has also lately expressed his be- lief in the same doctrine. We have observed that typhoid fever (the typhus of Nathan Smith, Gallup, and others) is the prevading fever of the Eastern States; and some believe that no other fever is met with in that region of country ; it prevails in a sporadic form, however, in nearly every sec- * [" The History, Diagnosis, and Treatment of Typhoid and Typhus Fever," &c, by Elisha Bartlett, M.D. Phil., 1842, 6vo.] tion of the Union, especially in the winter months. Dr. Bartlett states that he has seen it in Kentucky, where it is sometimes called the red tongue fever.—(Loc. cit.). Dr. J. P. Met- tauer has given an account of the prevalence of the disease in Middle Southern Virginia during the 13 years from 1816 to 1829, during which time he states that he treated more than 400 cases of it. Dr. M. regards synocha, typhoid, and typhus as varieties of the same fever ; and states that they all prevailed at different times in the same region of country. The synocha, " which was only the more open and well-de- veloped form of the disease," prevailed during dry and warm, and warm and damp seasons, and always as an endemico-epidemic of consid- erable extent. The typhus and typhoid fevers were generally confined to malarious districts ; and typhus did not often make its appearance until many cases of the typhoid affection had previously occurred in a family.* The typhoid fever has been very rife in the interior of the State of New-York for several years past, and has gradually spread over the whole of the Western States,t where, at times, it has caused considerable mortality. The migratory char- acter of this disease is one of its most singular features. It is also extensively prevalent in the large manufacturing villages of New-Eng- land, occurring far more frequently in some years and seasons than in others. Like other fevers, the typhoid assumes many forms and varieties; Louis makes three, one of which depends on the severity of the dis- ease ; Chomel describes several, as the in- flammatory, the bilious, the mucous, the ataxic, and the adynamic, depending on the predom- inance of certain symptoms. One form is called by Louis latent, where the usual morbid phenomena are not manifested. In some sea- sons the disease will be mild, and the mortality small; whde in others it will be severe and very fatal, the treatment being the same. Thus in the Massachusetts General Hospital, from 1822 to 1835, there were 303 cases of typhoid fever and 42 deaths, or about 1 in 7; in 1830, the deaths were 1 in 3i ; in 1831, 1 in 14£; in 1829,1 in 25. From 1832 to 1835, the num- ber of cases was 129, and the number of deaths 22, being a mortality of 1 in a little less than 6 ; while from 1836 to 1838, the number of ca- ses was 108, and the number of deaths 7, or 1 in 15. From November, 1836, to November, 1838, there were 55 successive cases without a single death; and the treatment was essen- tially the same during the whole of these pe- riods. The duration of the disease in this country varies in different years from 18 to 26 days. In 255 cases treated in the Massachu- setts General Hospital, between the years 1824 and 1838, the average duration, reckoning to the beginning of convalescence, was 22 days ; and of 186 cases at the same hospital, between Oct. 1st, 1833, and Oct. 1st, 1839, the average duration was 39 days.J According to Nathan Smith, the disease * [" Practical Observations on Continued Fever, as it prevailed in Middle Southern Virginia during the 13 Years from 1816 to 1829 inclusive," by John P. MettaUER, M.D., of Virginia. Am. Jour. Med. Sciences, July, 1843.] t ["Causes of Death in Typhoid Fever," by B. Rush Mitchill, of Ohio. Western Lancet, Oct., 1814, p. 268.] + [Jackson's Report on Typhoid Fever, p. 108, 109, 110, 111. Hale on the Typhoid Fever of New-England, p. 241.] 1200 FEVER, TYPHUS—in the United States. rarely terminates under the 14th day from the commencement, and rarely extends beyond the 60th.* Relapses are not unfrequent in this disease, and it is not often complicated with other affections. Peritonitis, from perforation of the intestine, is not an uncommon accident. Of the diagnosis and prognosis we have al- ready incidentally spoken. We may add that an extremely frequent pulse is a very danger- ous symptom ; so, also, are the noisy, irregu- lar respiration, violent delirium, deep somno- lence and coma, epileptic convulsions, or sub- sultus tendinum, great restlessness and agita- tion, the Hippocratic face, severe diarrhoea, in- voluntary discharges, haemorrhage from the bowels, retention of urine, erysipelas, &c. The prognosis can rarely be positive, as patients often recover from the most desperate condition. In the present stage of our knowledge, then, it is impossible, perhaps, to determine whether the disease, of which we have now given an account, be a specific one ; or whether it be but a variety of our continued fever, of which we have, according to some writers, an inflam- matory, and, as recogn ised by our best observ- ers, a true typhus; and occasionally that form called spotted fever. We are inclined to take the latter view of the subject, and think it de- sirable, as already remarked (considering the necessity of retaining the term typhoid to ex- press a state of the system met with in other diseases), to designate the phenomena of this fever by the name abdominal typhus, the name assigned to it by German writers. The fact of its general prevalence over our country, and that its ravages are gradually extending every year, must be our apology for the space allot- ted to it on these pages. The treatment of typhoid fever will hereaf- ter be considered. Am. Bibliog. and Refer.—J. P. Mettauer, Practical Observations on Continued Fever as it prevailed in Middle Southern Virginia during the 13 years from 1816 to 1829, In Am. Jour. Med. Sciences, July, 1843.—Enoch Hale, Re- marks on the Pathology of the Typhoid Fever of New-Eng- land, as exhibited in its Physical Signs and Anatomical.Ap- pcarances. Boston, 1819, 8vo, p. 77.—Elisha Bartlett, The History, Diagnosis, and Treatment of Typhoid and Typhus Fever, &c. Phil., 8vo, 1842.—B. Rush Mitchill, Causes of Death in Typhoid Fever. Western Lancet, Oct., 1844. —James Jackson, A Report on the Typhoid Fever in the Massachusetts General Hospital, from 1821 to 1835. Bos- ton, 1838, p. 96.—Thomas Hodgkin, On Fever. A Paper communicated to the Medical Department of the National Institute, Washington, D. C, and published in Boston Med. and Surg. Journal,vol. xxxi., p. 449.— T.Miller, Re- port on Dr. Hodgkin's Essay on Fever, in Bost. Med. and Surg. Journal, vol. xxxi., p. 4R9.— Wm. P. Johnston, Sec- ond Report on the same, in Ibid., p. 489.—H. J. Bowditch, In Translation of Louis's Researches on Typhoid Fever.— James Jackson, Jr., in Memoirs of.—W. W. Gerhard, in Am. Jour. Med. Sciences, Feb , 1837.—Samuel George Morton, Am. ed. of Mackintosh's Principles of Pathology and Prac- tice of Medicine. Phil., 1844.—L. M. Lawson, Am. ed. of Hope's Principles and illustrations of Pathological Anato- my. Cincinnati, 1844.—Thomas Miner, Typhus Syncopa- lis, Sinking Typhus, or the Spotted Fever of New-Eng- land, as it appeared in the Epidemic of 1823, in Middle- town, Conn., p. 48, 1825.—N. Y. Med. and Phys. Jour., vol. iv., p. 544.—A. T. Magill, A Prize Essay on the His- tory, Causes, and Treatment of Typhus Fever, in N. Y. Med. and Phys. Jour., vols. viii. and ix.—/. E. Cooke, in Transylvania Jour., vol. ii., 1831, p. 57.—John B. Brown, Account of a Fever which prevailed in the Boston Alms- house in 1817-18. New-England Jour., vol. vii., 1818.— George C. Shattuck, as quoted in a Memoir by M. Vallcix, Archives Generates de Medicine, Oct. and Nov., 1839; also in Medical Examiner for Feb. 29th and March 7th, J840.—J. Stewardson, ed. Elliotson's Practice. Typhus Fever.—That a form of fever cor- * [Smith's Med. and Surg. Memoirs, p. 56.] responding to the typhus of Great Britain, in which there are no anatomical lesions corre- sponding to those described as characterizing the typhoid fever of Louis, is now generally admitted as prevailing at times in our country. It. is the fever that attacks the inmates of our almshouses and passengers on board of emi- grant vessels, and many such cases are annu- ally received into the hospitals of this city. In March, 1842, the ship Eutaw arrived at New- York, after a passage of forty-two days, from Liverpool, with two hundred Irish passengers, of whom seventy were sick with typhus on her arrival. Among these there were eight deaths. In May, 1842, the bark Barlow arrived at this port from Greenock, after a passage of forty days, with fifty typhus patients, there hav- ing been three deaths before her arrival. And in August, 1840, twenty-one cases of typhus fever were admitted from a single vessel into the Boston Almshouse, of which four proved fatal. The prominent symptoms in these cases were, dulness of mind, deafness, stupor, suffusion of the eyes, and dinginess of the skin. The bow- els were torpid, and there was rarely any me- teorism or pain in the bowels, as in the typhoid variety. Dr. A. S. Doane, late quarantine physician of the port of New-York, and who treated much of the disease, states that the most striking and constant phenomena attend- ing it were, injection of the eyes, fuliginous as- pect of skin, and deafness. Diarrhoea was rarely observed, and the alvine discharges, when procured by medicine, were dark and of- fensive. The disease was evidently conta- gious, and Dr. D. remarks that during his con- nexion with the institution, a period of about three years, there were no less than sixteen individuals connected with the hospital who died of typhus fever contracted from the emi- grant patients.* True typhus has at different times prevailed epidemically in the almshouse of this city, attacking nurses and physicians, and often proving very fatal. We have treat- ed many cases of the disease in this city, in in- dividuals from on board passenger vessels, and in the narrow lanes, and crowded, filthy apart- ments of that class who apply to dispensaries for medical aid, and we have had abundant evidence of its contagiousness, as well as op- portunities for observing its characteristic phe- nomena. In 1843, some forty cases of genuine typhus occurred in the immediate neighbour- hood of an establishment in this city for the manufacture of lard oil from putrid pork, five of which came under our treatment in a single family ; all were marked by delirium and coma, dusky hue of skin, subsultus tendinum, consti- pated bowels, a thick, yellowish, pasty fur upon * [According to Dr. Gerhard, the spotted fever was similar in its nature to the British typhus. Dr. J. Jack- son thinks it was a different disease. Dr. Bartlett re- marks that, in many important particulars, it bore a very striking resemblance to true typhus. Dr. E. North called it a n*w petechial malignant typhus, which seems a very appropriate name. Dr. Hale speaks of many points of re- semblance between it and Dr. Armstrong's typhus, and also notices many strong points of difference. Dr. BaIT- lktt has remarked that it seems to belong to that diss of new and more or less temporary epidemics, each having its peculiar character, marked by its peculiar phenomena, and depending upon new and peculiar combinations of un- known morbific influences, which have always, from time to time, made their appearance, rather than to the clase of established and permanent maladies.] t [Bartlett on Typhoid and Typhus Fever. Phil, FEVER, TYPHUS—in the United States. 1201 the tongue, hot skin, and full pulse, &c, and their average duration was about thirty-five days. In these cases, there was no doubt whatever that the exciting cause of the disease was the emanations from the putrid meat. We have alluded to a typhus fever described by Dr. Mettauer as having prevailed for a period of thirteen years in Middle Southern Virginia (Am. Jour. Med. Sci., July, 1843), and which was attributed by him to malarious causes, and propagated, especially in the cold season, by personal contagion, or idio-malaria. The blacks were most subject to this form of fever. According to Dr. Gerhard, the epidemics which overran the Middle States between the years 1812 and 1820, were of typhus fever ; and of this disease Drs. Rush, Wistar, and Dorsey died. As a very perfect analysis of the symp- toms of this disease, we quote the following from the work of Dr. Bartlett (loc. cit.): " This disease, in the present state of our knowledge respecting it, may be defined in the following terms : Typhus fever is an acute af- fection ; occurring at all ages of life ; attacking, at least in cities, somewhat more frequently per- sons who are recent than those who are old or permanent residents; often transmitted direct- ly from one individual to another ; very much more common in the British Islands than any- where else, although prevailing at times in other countries, generally in the form of circumscri- bed epidemics ; often connected with the crowd- ing of many persons into small, dark, and poorly ventilated apartments, amid filth and destitu- tion ; sometimes sudden and sometimes grad- ual in its access ; attended at its commence- ment with chills, usually slight, and in many instances repeated ; then with morbid heat of the skin, in many cases very intense and pun- gent ; with increased quickness, with softness and feebleness of the pulse; with accelerated respiration; in many cases with the physical signs of bronchitis and pulmonary congestion ; with pain in the head, back, and limbs; dul- ness or perversion of the powers of the mind ; drowsiness or stupor ; dizziness, deafness, and ringing or buzzing in the ears ; morbid sensi- bility of the skin and muscles on pressure; extreme prostration of muscular strength; spasmodic twitchings of certain muscles ; dull and stupid expression of the countenance ; fu- liginous flush of the face ; suffusion of the eyes; with loss of appetite and with thirst; some- times with a slightly altered tongue, but in grave cases with a dry, red, brown, or black and fissured state of this organ ; sordes upon the teeth and gums; occasional nausea and vomiting; frequently with a constipated or sluggish state of the bowels; epigastric and abdominal pain and tenderness; the skin of the body and extremities being generally the seat of an abundant eruption, coming out, in most cases, between the fourth and seventh day of the disease, and declining at uncertain periods during the second and third week, con- sisting of small spots, generally somewhat ob- scurely defined and irregularly shaped, not in- frequently grouped and confluent, of a dusky, dingy red colour, not elevated above the sur- rounding surface, and disappearing only imper- fectly, or not at all, on pressure; the body of the patient, in grave cases, givin? out a pun- gent, offensive, and ammoniacal o lour; which 151 symptoms differ very widely in their duration, in their march, in their severity, and in their combinations in different cases, several of them being frequently wanting; but enough of them being generally present to characterize the dis- ease ; the most constant of which are the loss of strength, the stupor, the suffusion of the eyes, the fuliginous skin, and the dusky cuta- neous eruption ; which symptoms may either gradually diminish in severity, and finally dis- appear between the seventh and thirtieth day of the disease; or may increase in severity and terminate in death between the third and twen- tieth day from their access; the liability to a fatal termination being much less early than late in life ; the bodies of patients exhibiting, on examination after death, no constant path- ological changes of any of the organs ; but in a considerable, though varying proportion of cases, engorgement of the vessels of the brain, with moderate sub-arachnoid serous effusion; engorgement of the posterior portion of the lungs ; redness of the mucous membrane of the bronchia ; softening, or mamelonation of the mucous membrane of the stomach; the blood being generally of a dark colour, often fluid, or grumous; the coagula, when formed, soft and non-fibrinous; and the body, in many cases, running rapidly into decomposition ; which dis- ease, thus characterized and defined, consti- tutes a peculiar, individual affection, differing essentially from all others, although related by many analogies to typhoid fever." It is still in dispute whether there exists any essential diagnostic character between the typhus fever above described, and the typhoid fever of Paris and America. On this subject the following remarks of Dr. Gerhard are in point: " On considering the symptoms of typhus and typhoid fevers, we observe that the latter disease is not confined to any particular sea- son. It commonly attacks individuals of a par- ticulrr age, and exposed to some unaccustomed mode of life. It sometimes occurs at the same time that an epidemic of autumnal remittent or of typhus exists. I have seen it under both these circumstances, but I have always ob- served symptoms which distinguished it, from either. There could be no doubt of the cor- rectness of the diagnosis, for it was not, made in private practice, but in hospitals, where there were always a number of physicians and pupils present to correct and verify the facts. " These remarks are designed to show that the distinctive characters of these fevers are not such as in practice to allow them to be coo- founded together. Nor was it very difficult to acquire this facility of diagnosis, as all the bet- ter-instructed students easily attained it. That the very early stages of typhus and typhoid fe- vers resemble each other is true ; but in no greater degree than in the early, stages of ty- phoid fever and smallpox, which I have known to be mistaken for each other by the most ex- perienced observers. When the initial period of the fever is passed, the disease may be read- ily distinguished. Even very early, before the fever assumes its characteristic appearance, there is usually some fact which may throw light upon its nature. " 1. Dothinenteritis is usually a sporadic dis- ease, although it sometimes-appears as, a wide- 1202 FEVER, SYNOCHOID—Treatment of. spread epidemic. In the latter case the symp- toms are so well marked, that these are never doubtful, except in a few of the earliest exam- ples. Now typhus is very rarely sporadic; and if scattering cases do occur, they are gen- erally connected with an epidemic and follow it, as scattering cases of cholera were observ- ed for a long time after the great epidemic of 1832. " 2. Typhus is evidently very contagious; in the epidemic of 1836 it was quite as conta- gious as smallpox. I am fully convinced of its contagious nature from extensive observation as a physician to the hospital, and from the of- ficial visits and inquiries which I made as a member of the Board of Health. Dothinente- ritis is certainly not contagious under ordinary circumstances, although in some epidemics we have strong reason to believe that it becomes so. It bears in this respect the same relation to typhus fever that measles do to smallpox. " 3. The initial symptoms of the two affec- tions chiefly differ in the greater stupor, dul- ness, and prostration of typhus, which are in strong contrast to the moderate cephalalgia and disturbance of the senses in dothinenteritis. Still, there are now and then, perhaps once in twenty or thirty cases, some symptoms which are apparently common to the two forms of fever. Just as in the diagnosis of measles and scarlatina there is usually no dif- ficulty ; but we sometimes see cases of a hy- brid character in which the most experienced physicians may be doubtful. In two or three cases out of three hundred the symptoms of typhus and typhoid fever seemed blended to- gether ; but these were slight forms of disease, which are necessarily less distinct than those of a more severe type. In practice, such cases are too rare to give rise to any difficulty. " The more severe cases of dothinenteritis sometimes resemble typhus fever very closely, but the resemblance is confined to the symp- toms offered by the patient in the most aggra- vated period of the disease, and does not extend to the succession of symptoms. Indeed, if these cases of typhoid fever are examined at the early stages of the disease, they are cer- tainly more characteristic than the slighter va- rieties ; and although the symptoms occurring during a single day would lead us into error, the comparison of the successive changes will always guide us. "When the disease is completely formed, the characters on which the distinction be- tween the two forms of fevers rest are, 1. The suffusion of .the eyes, which occurs in every case, or nearly every case, of typhus fever, with the dusky-red aspect of the countenance; 2. The extreme stimor and inactivity of the mind, even when positive delirium does not exist; 3. We also observe in typhus no constant ab- dominal symptom, and at first merely dulness on percussion and feebleness of respiration at the posterior surface of the lungs ; 4. If to these symptoms be added the peculiar eruption of petechiae, which is scarcely ever absent in whites, there remains hardly a possibility of error. In the typhoid fever, we consider as distinctive characters the prostration, the som- nolence, the slow development of nervous symptoms, which are not so strongly marked as in typhus. The abdominal symptoms are tympanitis, pains in the abdomen, and diar- rhoea. The sibilant rhonchus is heard in the chest; and, lastly, there is an eruption of rose- coloured papulae and sudamina upon the skin. " It is not necessary to insist upon the diag- nosis between typhus and the ordinary autum- nal remittents. The peculiar season at which these latter diseases originate, their progress and termination, all differ too widely from the symptoms of typhus to allow of error, without extreme inaccuracy of observation. " Some rare cases of pneumonia, especially when they occur in drunkards or patients whose constitutions are enfeebled from other causes, resemble typhus in many particulars. Indeed, the diagnosis is vastly difficult, were it not for the petechial eruption, as the stupor is some- times considerable, and the suffusion of the face and eyes nearly as great as in typhus. If in these cases we are totally without knowl- edge of the early circumstances, we may occa- sionally mistake a case of pneumonia for typhus fever. But we could scarcely confound the pneumonia, which appears as a mere compli- cation in typhus, with the original inflamma- tion of the lungs. In some of these cases we derive less benefit than we could anticipate from the physical signs, because pneumonia may be present and be readily distinguished by auscultation, but, at the same time, be strictly secondary. Neither bronchitis nor angina re- semble typhus, unless they occur as an epi- demic."—(Am. Jour. Med. Sciences, vol. xx., p. 307.) It remains for future observations to deter- mine the precise relations whfch these diseases hold towards each other.] 524. XXIV. Treatment of Synochoid and Typhoid Fevers.—i. Treatment of Synochoid Fever.—In this fever, as well as in all others in temperate climates, the indications and cir- cumstances stated above (Y 123, 124) as deserv- ing of especial attention should be strictly ob- served. The prevailing epidemic, and the changes that take place in its nature, or char- acteristic states of vital action, with its prog- ress and with the season, should be carefully studied and made the basis of treatment. Some difficulty may occur, at first, in coming to just conclusions ; but it will vanish with the extent of observation, especially when diligence has been used. The chief points to which the at- tention of the practitioner will be directed are, the nature and concurrence of the causes, the extent to which they may have affected vital manifestations, the degree of excitement or vascular reaction in connexion with nervous power, the state of the circulating and secreted fluids, and the nature and amount of local com- plications or determinations. The physician who has studied, in an intimate manner, the various phases of disordered vital manifesta- tion, will have little difficulty in recognising the chief characteristics of fever under the ever- shifting circumstances in which they present themselves, and in appropriating accordingly his method of cure. 525. A. The ancients observed carefully the spontaneous changes which take place in fever, and conduce to recovery (see art. Crisis) ; and they were guided, in forming their indications of cure, by these changes, which they merely attempted to promote or to imitate. This FEVER, SYNOCHOID—Treatment of. 1203 mode of practice may be followed in synochoid fever more successfully, perhaps, than in any other. Yet it will be better to combine with it the more modern indication of resorting to such means as may subdue the more urgent symptoms, and avert contingent danger.—a. If the patient be seen as early as the premonitory and invading stages, the impending disease may be averted by the means advised above (v 121, 122), more especially by emetics, warm diaphoretics, and the vapour bath. But when ex- citement has commenced, the treatment should be antiphlogistic. In this stage we should en- deavour, by a careful examination of the symp- toms, to ascertain the existence of local com- plications ; and, having determined their ab- sence, the question will then be as to having recourse to blood-letting. I have already con- sidered this topic so fully (v 128-139), that nothing farther need be here advanced. If the nature of the prevailing epidemic, or the degree of reaction, require depletions, the earlier in this stage they are resorted to the better. But even then they require caution and dis- crimination. If the excitement be slight, and the patient neither robust nor plethoric, and more especially if the causes and circumstances connected with the origin of the disease be of a depressing nature, they will be better withheld. 526. b. The exhibition of emetics in the stage of excitement was advised by many of the an- cients, and practised by some of the most re- cent writers, although objected to by others. The reason of this difference of opinion is very obvious. There are states, even of this stage, in which they will be of service, and others in which they will be injurious. When reaction is slight—when the patient is not plethoric, has not experienced full vomiting, and does not complain of pain or of tenderness in the epigastrium or hypochondria, then emetics may be exhibited. But if the excitement be great, with determina- tion to the head, and if the patient have already vomited freely, and more especially if the symp- toms just mentioned be present, they should not be prescribed. (See v 149.) 527. c. Purgatives, so much decried by Brous- sais, and with some justice as respects several states of fever prevalent in France, are cer- tainly of very great service in the common con- tinued fever of this climate, when employed with a cautious discrimination. Early in this disease, calomel, either with or without James's powder, may be given at night, and a purgative draught in the morning. At a more advanced stage, calomel, or hydrargyrum cum creta, may be conjoined with rhubarb. If the stomach be too irritable to retain the more common purga- tives, a full dose of calomel will generally be retained ; but its action should be promoted by enemata (see F. 140, 144). During the febrile excitement, and when the bowels are sluggish, the stronger saline purgatives may be given in solution, in small doses and at short intervals, with refrigerants (F. 440, 441). The remarks already offered upon this subject (v 150, 151) will guide the practitioner as to the choice of purgatives, and the extent to which they should be prescribed. In this fever especially, it can never be injurious to give them to the extent of freely evacuating morbid accumulations in the bowels, and of promoting the alvine secre- tions and excretions. When the faeces are very offensive, greater mischief will accrue from allowing them to remain, even for a short time, in the bowels, than from too active meas- ures in evacuating them 528. d. The remarks that have been offered above respecting refrigerants (v 139, 140), diaph- oretics (Y 152), and diuretics (v 153), are entirely applicable to this form of fever. The cold affu- sion, which formerly attracted so much more, and now so much less attention than it de- serves, is more appropriate in this than in any other disease. This practice, although resort- ed to by the ancients and in Eastern countries, was but little known in this until it was em- ployed by Wright and Jackson. The work of Dr. Currie on the subject first brought it into fashion, but now it certainly has not fashion in its favour. When the excitement is fully de- veloped, and the heat of skin above the natural standard, when there is no sense of chilliness, and when the surface is hot and unperspirable, the cold affusion may be employed. Dr. Cur- rie directed water of the temperature of from 40° to 60° or 70°, and preferred the hours from six to nine in the evening for its use. In cases of debility, the cool or tepid affusion is more appropriate. I have resorted to cold affusion over the whole body in several cases of fever in a warm climate, but I was not induced, by its effects, to entertain a high opinion of it. The affusion of cold, cool, or tepid water on the head, when this part is prominently affect- ed, and cold-sponging the surface, are more beneficial, and admit of more general applica- tion. Dr. Currie believed that the general af- fusion had the effect of lowering the pulse and the morbid heat, of inducing perspiration and sleep, and of cutting short the fever. I have never seen it succeed unequivocally in produ- cing the latter effects, but have remarked that the excitement returned shortly after its use. In the complication with disease of any of the thoracic or abdominal viscera, it should not be used (6 141). 529. B. Of the Complications.—a. Predomi- nant affection of the head has received attention above (y 165). What I have there stated is applicable to this complication of common con- tinued fever. Blood-letting is especially requi- site, but its amount, and the mode of perform- ing it, should entirely depend upon the symp- toms and the stage of the disease. The cold affusion on the head, and purgatives, are the next in importance. When the cerebral affec- tion has been preceded or attended by diarrhoea, purgatives should be prescribed with caution. Rhubarb, with hydrargyrum cum creta, given so as to evacuate morbid matters, and promo- ted by suitable enemata (F. 140), will be then sufficient. When delirium is the principal symp- tom, care should be taken to discriminate ac- curately the states of vascular action and of vital power. If it be unattended by increased heat of scalp, the pulse being very quick and soft, and the countenance sunk or pale, and especially if it have followed intestinal disorder, all lowering agents should be laid aside, and restoratives with opiates, and mild nourish- ment in small quantities, prescribed. When fever occurs in persons addicted to spirituous or other intoxicating liquors, the cerebral affec- tion is apt to become very severe, and to be attended with delirium, and often with tremour. 1204 FEVER, TYPHOID—Treatment of. In such cases, depletions should be used with caution. If tremour, irritability, &c, appear, opium, with or without camphor, should be exhibited. In other respects, the means ad- vised in the article Delirium, according to the pathological states upon which it depends, will be here appropriate. I have repeatedly seen the cerebral symptoms greatly aggravated by the application of a blister to the scalp at a too early stage of the disease. Blisters should be applied preferably on the nape, but never on the head, unless there be profound coma, or low delirium with great exhaustion of vital power, as more fully shown in the articles Coma (v 16) and Delirium (y 19). 530. b. The observations already made re- specting the pulmonary complications (y 160-163) are mostly applicable to those occurring in this form of fever. Bronchitis is the most common affection, and requires the treatment above ad- vised (y 161,162). When the substance of the lungs, or the pleura, is implicated, vascular de- pletions ought to be early practised. But even in these cases, we should recollect that blood- letting must be employed with greater caution than in inflammations occurring primarily and in healthy constitutions. It is in this fever, and in its pulmonary complications especially, that antimonials may be given with greatest freedom. After depletions and antimonials have been carried as far as seems prudent, blisters, or other external derivatives, should be used. If the air-passages become loaded with mucus, antimony, or ipecacuanha, or sul- phate of zinc may be given so as to excite full vomiting. 531. c. Predominant affections of the digestive mucous surface have already received attention, and the treatment there recommended (y 155- 159) is quite appropriate in these complications of this form of fever. In the gastric state of disorder, particularly when much pain and ten- derness, with irritability, exist, local depletions should be early employed ; and a full dose of calomel, given shortly afterward, will generally allay what may remain of these symptoms. Enemata, also, will assist materially in produ- cing this effect, and evacuate morbid matters from the bowels. Small, but often-repeated doses of hydrochlorate of ammonia, or of the nitrate of potash with the carbonate of soda ; or camphor julep, with the solution of acetate of ammonia, and nitre, or spirit of nitric aether, will afterward be extremely beneficial. Even in this form of fever, but still more in the ady- namic, we should be cautious not to be misled by the persistence of pain and tenderness at the epigastrium; or induced to prescribe too frequent or too large depletions with the view of overcoming these symptoms. They may never be removed by these means, however freely employed; for, notwithstanding the ar- guments of Broussais for their origin in inflam- matory action, I believe that they depend more upon the altered state of the organic nervous sensibility than upon increased vascular action in the stomach. 532. In the enteric complication the treatment will depend upon the stage of fever at which it appears, and the progress it may have itself made. Local depletions, external derivatives, and the other means enumerated above (y 156- 159), are generally necessary. If bloody or ochrey discharges are observed, especially late in the disease, the terebinthinate medicines, or the acetate of lead with opium, as advised by Dr. Bardsley, will be found the most efficient remedies. If the powers of the system become much reduced, gentle tonics, with the chlo- rates, as the infusion of valerian with the chlo- rate of potash, and paregoric elixir, will be of essential service. The following medicines will prove of great use in earlier stages of this complication, after local depletions, especially when aided by external rubefacients and deriv- atives. In slight cases, either of them may be given, according to circumstances; in the more urgent, both may be taken alternately, at intervals of three hours. No. 223. ft Sods Carbon, gr. x.; Potassa Nitratis gr viij.; Tinct. Camphorae Comp. 3j.; Mist. Camphorae (vel Infusi Valerianae) §x.; Sirupi Aurantii 3ss. M. Fiat Hans- tus, sextis horis sumendus. No. 224. ft Camphorae rasa? et subacte gr. ss.—j. ; Pulv. Ipecacuanha Comp. gr. iv.—vj. ; Hydrarg. cum Creta gr. iij.—v.; Sirupi Simp. q. s. ut fiant Pilulae ij. vel iij. sextl qu&que hora sumendae. 533. ii. Treatment of Typhoid Fevers.— The treatment of this class of fevers is the most difficult in practical medicine. If the physician possess not just views as to the dif- ferent and varying states of vital action, and as to their influence in producing organic le- sion ; if he be not enlightened as to physiolo- gical pathology, as well as to pathological anatomy ; if his knowledge of the instruments of his art be not adequately varied and com- prehensive ; if his resources be not great, and based on science, he administers to a patient in any of the forms of typhoid fever with an equal chance of doing mischief, or of affording benefit; and he may as well adopt his plan of treatment from the "hazard of the die," as to attempt to reason on the matter. It is better that the patient were left to the spontaneous efforts of nature than that he should fall into the hands of such a practitioner. If we look back to the influence of theory and system in the treatment of these diseases, to the impor- tance bestowed on names, and to the manner in which names have been confounded with, or substituted for indefinite and varying enti- ties, we shall not be at a loss to explain where- fore it has often been a matter of difficulty to decide whether or not medical interference has proved beneficial or injurious. This is, how- ever, not an opprobrium to our science, but a proof of its difficulties, and of the ill-founded pretensions of many of its professors and teach- ers. In our own days we have seen preten- sions to which ignorance gave confidence, and for which professional cant procured currency, obtain a credence which now seems surprising, and produce results which the adequately in- formed always anticipated. We have witness- ed the promulgation of doctrines, and of modes of practice, warranted neither by an acquaint- ance with vital actions, nor by a knowledge of, nor regard to facts, lead to the most serious consequences; and have remarked, moreover, the power they obtained over those who were either unwilling or unable to inquire into their truth. But we have also seen, in the brief space of two or three years, the illusion vanish before the increasing and spreading lights of pathological and practical knowledge. 534. The difficulties attendant upon the treat- FEVER, TYPHOID—Treatment of. 1205 ment of this class of fevers depend chiefly upon the varying states of vital action in their course; the modifications and complications they pre- sent in different circumstances and epidemics, and the inadequate means of discrimination in our power between the changes induced by treatment and those taking place spontaneous- ly. It is not also from the effects produced upon a few detached cases that we can judge sufficiently of the efficacy of certain remedies, but from the results in a number, from the rate of mortality in various circumstances, and in different epidemics. Whatever may have been the method advised by writers—too many of whom have written from motives wide from those by which alone they ought to have been actuated—we shall find, upon close inquiry, that the general mortality has been such as to de- monstrate its little efficacy, or to show the small superiority possessed by it over others. 535. The ancients observed the changes which take place in the course of fevers with great attention, attributed recovery to the critical evacuations which frequently occurred in their advanced stages, and did not attempt to inter- fere with the efforts of nature as long as the disease pursued a simple and mild course, but interposed in order to accelerate and replace evacuations when they did not occur after a certain period, or were interrupted by any cir- cumstance. The chief fallacy in this doctrine is, that the evacuation, when it occurred, was mistaken for the cause of the amendment, in- stead of being viewed as the effect, and as one of the signs by which this change is often in- dicated. 536. The physicians who, in modern times, attributed an important part to putridity of the humours, recognised merely a portion of the mischief, and that often the most remote and contingent, and mistook, in great measure, both its origin and nature. They had recourse to camphor, bark, musk, and various preparations, both vegetable and mineral, possessing antisep- tic properties ; and, if they had employed them in appropriate periods and states of the disease, the benefit derived from them would have been much less equivocal. But, mistaking the ori- gin of the phenomena usually called putrid, they frequently prescribed these medicines im- properly ; and while endeavouring, by an early exhibition of them, to prevent putridity, they actually often accelerated or favoured its oc- currence. 537. A nearly similar mode of treatment was advised by Brown, and his once numerous fol- lowers on the Continent; but it was based upon a different doctrine—upon the predominance of the asthenic diathesis and its consequences. Although wine, opium, tonics, and stimulants were recommended by them, in various forms and combinations, with advantage, in certain states of typhoid fevers, particularly in the lat- ter stages, yet the evils resulting from an early recourse to them were also sufficiently evident, and at last became manifest even to the disci- ples of this school. That this practice, and the modifications introduced by its partisans, did not prove so injurious in the treatment of fe- ver, especially on the Continent, as may be supposed, is accounted for by the circumstance that depressed vital power, with septic chan- ges in the fluids in the last stages, character- ized the much larger proportion of fevers preva- lent for several years after its promulgation. But the appearance of exanthematic typhus in the north of Italy, at the close of the last cen- tury, opened the eyes of Rasori to the impro- priety of having recourse to stimulants in its treatment, and laid the foundation for the doc- trine and practice of contra-stimulus. The gen- eral character of the petechial fevers prevalent about the commencement of the present centu- ry in Italy and Germany was such as I have delineated in the section on typhus (y 485), with more or less inflammatory or irritative action in the stage of excitement, the exan- thematous eruption in this stage being frequent- ly mistaken for petechias, and the appearance of these, and of other adynamic symptoms, be- ing favoured by the vascular reaction which preceded them. 538. The administration of the potassis tar- trate of antimony in large doses was the princi- pal treatment employed by Rasori. When the patient was young and robust, and the disease had not reached the acme of excitement, he di- rected a moderate blood-letting at the outset, and immediately afterward four, six, eight, ten, or twelve grains of tartar emetic, or even more, in solution. He prescribed this medicine in smaller doses subsequently, or substituted for it the kermes mineral, conjoined with nitre, and in doses of one grain, or of a grain and a half, every half hour or hour, or every two hours, according to the degree of vascular excitement. He often gave the tartar emetic and kermes al- ternately. Rasori also employed purgatives, particularly when the antimony did not act suf- ficiently upon the bowels; preferring neutral salts, manna, and tamarinds in large doses, and administering them, in other cases, in en- emata. He enforced a cooling regimen and severe diet, and allowed only refrigerant bev- erages. The success of this treatment is sta- ted to have been great; and its propriety, as well as success, may be admitted, when em- ployed in an epidemic characterized by high vascular excitement at its commencement, and when adopted sufficiently early after reaction has taken place, and in previously healthy per- sons. But in other states of typhoid fever, and in the latter stages especially, the large doses of antimony here advised appear not, a priori, to he suitable means. It should, however, be admitted that the exhibition of the potassio tar- trate of antimony, in the advanced stages of this fever, has never been satisfactorily tried, either in this country or in France and Germa- ny. That it may be found not so inappropriate as generally considered, is an inference which the trials made of it, very recently, by Dr. Graves, of Dublin, fully warrant. 539. The pathological tenets lately prevalent in France have, as M. Chomel states, prevent- ed the treatment of Rasori from being adopt- ed, or even tried in that country. The doc- trine of Broussais was opposed to this, and every other means that seemed to its support- ers likely to aggravate the inflammatory action of the digestive mucous surface, which they supposed to be the cause of all fevers. If we examine the practical tenets of this school, we shall find more than one postulatum assumed as fully established, although admitting not only of doubt, but even of disproval. That fever does 1206 FEVER, TYPHOID—Treatment of. not depend upon this lesion, although predom- inant morbid action in the digestive canal may appear in many cases, and in some fevers more frequently than in others, has been already shown. And, granting that this morbid action is attended by vascular injection of the mucous membrane, it still remains to be proved that it is the same kind of affection as inflammation. That it is not the same as primary and sthenic inflammation, its phenomena and results, as well as the juvantia and ladentia, sufficiently prove. Even granting the doctrine of Brous- sais in its fullest range, it still remains to be demonstrated that the treatment advised is that which is the most beneficial or the most appropriate in the numerous and varying mor- bid conditions which fevers assume ; and it, moreover, should be shown that the means which the espousers of this doctrine reprobate are one whit more prejudicial than those which they laud. In a class of diseases so varying, and even opposite, as to their pathological states, as fevers are, not only in their different forms, but also in the same case at different stages, the success of various remedies cannot be predicated from doctrinal tenets. However ingenious the theory and close the reasoning by which we are led to practical inferences, careful experiment and repeated observation are necessary to test the character of any method of cure; and even were we to adopt the views of Broussais, to these tests we ought to resort before we should decide between the efficacy of gum-water and leeches on the one hand, and that of antimony and purgatives on the other ; or, indeed, respecting the propriety of any remedy whatever. 540. The pathological views of Hoffmann, and the modifications of them by Sauvages and Cullen, although entirely based upon solidism, were favourable to rational modes of practice. These views, in the varying explanations of them furnished by Heberden, Fordyce, and others, have very generally guided practition- ers in this country in the treatment of typhoid fevers, until Dr. Hamilton introduced a modi- fication of the usual practice, or induced them to have a more frequent recourse to purgatives than had previously been ventured upon. That these remedies, especially when judiciously se- lected and combined, do not produce the mis- chievous effects in typhus which Broussais supposes them to produce, even when given in cases the most favourable to his views, I am convinced by experience, and many of his dis- ciples are at last opening their eyes to the fact. MM. Bretonneau, Andral, and others, more or less partial favourers of his doctrine, have recently so far discarded the practical tenets of their school as to venture on the exhibition of these medicines ; and, as M. Chomel justly remarks, have found that the dread of them so long entertained is unjust, and that they may be employed early, in many cases of typhus, with great benefit. Where, however, there is reason to suspect the existence, or even the commencement, of ulceration, the impropriety of having recourse to them, unless with the circumspection and in the manner hereafter to be mentioned, cannot be doubted. But ulcera- tion seldom occurs before the twelfth day of the disease ; and if they have been judiciously employed previously, I believe that it will very rarely take place either then or at a later pe- riod. 541. The humoral pathology, although su- perseded very generally by solidism, since the days of Hoffmann, still continued to be par- tially adopted by some practitioners in different ! parts of the Continent. It has been lately re- vived in a too exclusive manner in this coun- try. Among those who have espoused views of this kind may be mentioned Dr. Stoker, Dr. Clanny, and, still more recently, Dr. Stevens, each of whom has endeavoured to establish the early predominance of morbid states of the blood. These views have been already partial- ly discussed, and I have now nothing farther to add respecting them than that the changes of the blood for which Dr. Stoker argues are those which have been above stated (y 520), and which refer merely to its external appear- ances. Dr. Clanny insists chiefly on the dim- inution, in typhus, of the carbonic acid, which he supposes the blood to contain in health. He recommends the use of fluids containing or evolving this gas, as effervescing draughts, Selt- zer water, &c. M. Chomel states that he gave this practice a trial in the Hotel Dieu during two years, and that, although the cases in which he employed it were not numerous, they satis- fied him that it did not influence the usual re- sults, and that he preferred, therefore, to try other means, the inefficacy of which had not been so fully shown. Of the treatment of Dr. Stevens, in respect of this class of fevers, I entertain similar opinions to those expressed above (y 387). In two cases of low nervous fever to which I was lately called, at a period, however, too late to expect benefit from any treatment, I prescribed the remedies this wri- ter has advised, but without any effect. 542. If the rational method of treatment, or that which is modified according to the form, state, or stage of the disease, is not much more suc- cessful than that which is dictated in the spirit of system or of empiricism, it has at least this to recommend it, that it brings the results of science to bear upon existing pathological states, both vital and structural. Although not admitting so readily of the usual tests of success as more empirical methods, the expe- rienced physician will readily form a tolerably accurate idea of the circumstances either pro- moting or preventing favourable results. He will make due allowances for the forms and pe- riods of the disease, the characters of the epi- demic, the influence of season, and for the nu- merous circumstances appertaining to individ- ual cases ; and he will at once perceive that the means that are beneficial in one epidemic, or in one form of fever, or in certain cases, will be most injurious in others. In the present state of our knowledge, the rational method of cure is that which is most appropriate to the different varieties and stages of fever. Ac- cording to it, indications or intentions are deri- ved from a due estimate of existing symptoms and signs, and of the pathological conditions evinced by them. While it comprises every method of cure, and all kinds of means, it adapts them to the states of the disease and of the pa- tient. The judicious physician employs, accord- ing to circumstances, remedies the most oppo- site ; and, in different cases, or in different peri- ods of the same case, he has recourse to seda- FEVER, TYPHOID—Treatment of. 1207 tives, to refrigerants, to evacuants, to tonics, to astringents, to stimulants, or to antiseptics. He neglects no means, but adopts none exclu- sively; and while interpreting the value of symptoms, and inferring the morbid states pro- ducing them, he endeavours to select and to combine the medicines whose known opera- tions are such as are most likely to remove these states, or to prevent the accession of oth- ers usually supervening in the course of the disease, and increasing its danger. I will now proceed to consider, 1st. The treatment appro- priate to the different stages of typhoid fever ; 2dly. The modifications required by its differ- ent forms and complications; and, 3dly. The means recommended in a special manner, and thn circumstances or states of the disease in which they may afford benefit. 543. A. The Treatment appropriate to the sta- ges.—a. In the premonitory stage, and while that of invasion is not fully formed, the future fever may be checked or prevented by the shower- bath, followed by frictions of the surface; by an emetic, or by a warm stomachic purgative ; or by a warm or vapour bath ; or by all these following in succession ; and in some cases, also, by warm diluents or diaphoretics; but this result cannot be depended upon.—b. When the stage of invasion is pronounced, bleeding, hot stimulants, &c., are hurtful, or even dan- gerous. Tepid and warm diluents, and the warmth of bed, are the most suitable means. If vomiting accompany this stage, it may be in- creased by tepid and emollient diluents. If nausea only be complained of, and if there be little pain, tenderness, or tension in the hypo- chondria and epigastrium, an emetic may be given, and its action promoted by these means. This treatment will generally shorten the chills, &c, characterizing this period, and favour a relaxation of the surface, or the occurrence of moderate reaction. 544. c. In the stage of excitement the treat- ment must altogether depend upon the degree in which reaction is developed, and the manner in which the brain, the lungs, or the digestive canal appears to suffer. If the fever does not present, early in this state, the characters of low nervous fever to their full extent, or those of an adynamic or of a putrid or septic kind, then a small or moderate blood-letting may be prescribed; but the effects at the time of the operation should be carefully observed. If the patient be young or robust, previously healthy and well fed, then a more copious depletion may be practised, if he be seen early. Even in the lower states of this fever, if any of the viscera just named be prominently affected, a local depletion, either by leeches or by cupping, may be employed. But if the period of excite- ment be far advanced; if the fever be simple or mild ; if it have passed the tenth day ; and if it be the true or exanthematic typhus, unat- tended by inflammatory associations ; blood- letting will seldom be of service, and it may in- terrupt the regular and favourable course of the disease, particularly the latter form of it. In a large number of cases in which M. Louis states blood-letting to have been tried, and in which it appears to have been indicated, the advantage procured by it 6eems to have been alight; but sufficient to increase, to a 6mall amount, the proportion of recoveries, and to I diminish the duration of the disease. Emetics have been advised also in this stage; and, in cases where the chills return on successive days, or frequently alternate with flushes, I be- lieve that they will be found of service. Hil- denbrand directs them in the first, second, or third day, or even later; having premised a blood-letting in the cases indicating it; and prefers a large dose of ipecacuanha, with a grain of tartar emetic. Next to emetics, pur- gatives are of advantage. At an early period, or before the eighth or ninth day, a full dose of calomel, either alone or with rhubarb, may be given; or jalap, with cream of tartar; and their action promoted by moderate doses of the neutral salts, or by manna, tamarinds, &c, ac- cording to circumstances. These clear away morbid secretions and mucous sordes from the digestive surface ; which, if allowed to remain, would favour the occurrence of the morbid changes in the intestines. If, however, the bowels have been much relaxed, and still con- tinue so, it will be preferable to give an occa- sional dose of hydrargyrum cum creta, with rhubarb, and ipecacuanha, which will promote a healthy state of the mucous surface, and fa- cilitate the evacuation of morbid secretions. If the bowels be only gently open, the circum- stance is favourable ; but an inordinate action of them must be moderated by the above med- icine, or by others hereafter to be mentioned, lest intestinal ulceration and perforation be the ultimate result. At the same time, care should be taken not to produce a sudden change or constipation, otherwise the cerebral or nervous symptoms will generally be much aggravated, and a tendency to effusion on the brain be pro- duced. Diaphoretics, suitable to the state of the symptoms, either variously combined, or associated with diuretics, may be given from time to time. Of these, the more refrigerant, with small doses of camphor, will be most ser- viceable ; and either some one of those in the Appendix (F. 431, 436, 440, 818, 865), or the following, may be prescribed : No. 225. ft Camphorte rasas gr. ss.—j. ; Potassas Nitratis gr. iij.; Pulv. Acacia; gr. ij.; Mucilag. Acacias q. s. M. Fiant Pilulae ij. quartis horis sumendaTe. No. 226. ft Mist. Camphorae ?j.; Liq. Ammoniae Aceta- tis 3j—iij.; Ammoniae Hydrochloratis gr. iv. ; Sirupi Li- monis 3j. M. Fiat Haustus, quarta quaque hora capien- dus ; vel interdum, sccundis horis, pilulas et haustus, alter- nis vicibus, sumantur. 545. d. In the nervous stage the debility is more real; irritability is more exhausted, and the sensorium more severely and uniformly af- fected. The functions of the skin, and frequent- ly those of the bowels, are also more disturbed than before. The indications are to support or stimulate the system, according to the forms the disease assumes. Blisters may be employ- ed in this stage—seldom before. They favour- ably impress the nervous system, check the tendency to diarrhoea and affection of the in- testinal mucous surface, and render the skin more perspirable. They are most serviceable at the commencement of this stage ; and are best applied on the nape of the neck, behind both ears, or on the calves of the leg. Camphor is now one of the best remedies that can be ex- hibited. While it promotes nervous power, it relaxes the skin, and does not increase inflam- matory action, but rather tends to allay it, par- ticularly the nervous and cachectic forms of it, 1208 FEVER, TYPHOID—Treatment of the Complications. which alone can exist in this disease. It should be given in larger doses in this stage, more especially of the malignant or putrid form. From twelve to twenty grains may be exhibit- ed in the twenty-four hours. Hildenbrand advises, in the latter part of this stage, medium doses of camphor ; or one grain every two hours, with an infusion of arnica and angelica root. He considers that these lessen the stupor, giddiness, and delirium; act favourably on the skin ; and prevent the tendency to diarrhoea. Emetics are sometimes beneficial in this stage, when they have been neglected in the previous one, or contra-indicated. Purgatives are of service only when the bowels require assist- ance. They should be given with the intention of evacuating morbid matters, of preventing the injurious impression made by such matters upon the intestinal mucous surface, and of pro- moting a healthy action of the abdominal emunctories. Hydrargyrum cum creta and rhubarb, and the infusion of the latter with the milder saline substances, in a state of efferves- cence, are the most appropriate. These pre- serve the tone of the digestive mucous surface, while they enable it to throw off faecal collec- tions. Their action may be occasionally pro- moted by emollient and gently laxative enemata. I doubt much the propriety of exhibiting calo- mel, or any of the drastic purgatives, in this stage; and I believe that the more active neu- tral salts exhaust the strength and produce wa- tery stools in this period, particularly if they be exhibited in any quantity. It is in the com- mon, or synochoid form of fever, or at the com- mencement of this, that they may be employed. In the latter stages of low fevers, calomel and cathartics are apt to increase the intestinal symptoms, or to determine an irritative action of the bowels, liable to terminate in the lesions already noticed. 546. e. When the disease has reached its acme, or is approaching the fourteenth day, the treatment should very much depend upon the predominant symptoms, upon what has been already done, and on the effects observed. If no unfavourable symptoms are present, mild saline diaphoretics, as camphor mixture, with liquor ammoniae acetatis, &c, or the former with the alkaline bi-carbonates and citric acid, or lemon juice, in effervescence, and mild de- mulcent diluents, are all that are required. The chief intention at this stage is to favour a genial perspiration. The temperature of both medicines and drinks should not be lower than tepid. If the disease is complicated, particu- larly at this period, or is proceeding irregular- ly, the treatment must be varied, as will be hereafter shown. If a crisis take place, or the more urgent symptoms gradually subside, the means should vary with the degree of vital de- pression evinced. Both tonics and stimulants should, at first, be mild, in moderate doses, and suited to the state of the pulse, and of the skin and bowels. At first, a cold infusion of cin- chona, or the decoction, may be given, with the solution of the acetate of ammonia, or with either of the alkaline bi-carbonates and citric acid, in effervescence. The infusion of vale- rian may also be substituted for the cinchona, and given as directed above. The regimen, diet, and convalescence should be managed with strict reference to the forms and complica- tions of individual cases, as will be hereafter shown. 547. B. The Treatment of the Varieties and Complications of Typhoid Fever.—a. In the sim- ple typhoid, or nervous fever, when it commences as described above (y 459), the period of excite- ment being characterized by little or slight re- action, blood-letting is seldom beneficial; or lo- cal bleeding, in a situation indicated by the prominent affection, will only be required. If the pulse be very rapid, or soft, and open; if the prostration be great, and the tongue assume a dark colour; and particularly if this state exist at the commencement of the disease, vascular depletions will be injurious. The in- dications enumerated above (y 132, 133) will farther serve to point out when they may or may not be resorted to. An emetic is always of service, particularly if there be nausea ; and if vomiting be spontaneous, it should be mod- erately assisted, as already advised. The bowels should be evacuated early in the dis- ease by mild purgatives. Those already men- tioned are the most appropriate, or fresh castor oil may be used. They may be repeated occa- sionally, with the views I have stated, but with due caution, lest they induce too great exhaus- tion, or favour the supervention of intestinal disorder. While the heat of skin continues, tepid or cold sponging the surface is grateful to the patient, diminishes the restlessness, and favours the operation of diaphoretics during this state. If diaphoresis occur, it should be pro- moted by mild, tepid diluents, either simple or medicated, in the manner about to be noticed. If copious perspirations occur, especially about the acme of the disease, or at a critical time, they should not be arrested unless they in- crease the exhaustion, or are attended by signs of septic deliquescence. In the nervous stage the treatment directed above should be employ- ed (Y 545). 548. a. Prominent affection or consecutive in- flammation of the respiratory organs, in the ner- vous form of typhoid fever, requires the utmost discrimination on the part of the practitioner for its successful treatment. The subject has been admirably elucidated by Dr. Stokes, in his truly excellent published lectures on fever. The chest should be carefully examined by the steth- oscope, in order to ascertain, as accurately as possible, the state of pulmonary disorder, and to determine whether the symptoms referred to this organ be symptomatic, or dependant upon inflammatory action or active congestion. The able pathologist just mentioned remarks that when the bronchial surface is chiefly affected, there is much more lividity of the countenance than when a portion of the substance of the lungs is diseased. This symptom will gener- ally verify the reports of auscultation. But the treatment will entirely depend upon the nature of the bronchial affection. If the dyspnoea and other pulmonary symptoms depend upon inflam- matory irritation rather than upon increased secretion from the mucous surface; if there be heat of skin, more or less vascular reaction, and if the patient be young and robust, bleeding, general or local, will be necessary, according to the severity of the symptoms and stage of "the disease. If, however, these symptoms depend chiefly upon a copious secretion from the bron- chial surface, as will be shown by the steth- FEVER, TYPHOID—Treatment of the Complications. 1209 oscope, bleeding will be most injurious, and very decided means of an opposite nature will be requisite in order to prevent contingent as- phyxy. In this latter case, extensive counter-ir- ritation, the mistura ammoniaca, or the decoctum senega with camphor, ammonia, the tinctura cam- phora composita, or other stimulating expecto- rants, must be resorted to, according to the ur- gency of the case, particularly if lividity of the face exist. When the strength is very much reduced, wine will also be necessary, with light nourishment. The temperature of the surface should be kept up. Dr. Stokes very properly directs the patient to be enveloped in soft flan- nel. When the bronchial affection is more strictly inflammatory, and the secretion does not interrupt materially the functions of the lungs, antimonials may follow the bleeding. But in either case, if the symptoms leferred to this organ, particularly the dyspnoea, or the cough, become urgent, and be attended by the tracheal rattle, an emetic of ipecacuanha, or of sulphate of zinc, should he immediately exhib- ited. In this state Dr. Graves, whose exten- sive resources, in matters of difficulty, I have had frequent occasion to notice, has tried the application of moxas in the course of the eighth pair of nerves, and the use of the sulphate of quinine and opium in enemata ; these latter ex- erting a powerful influence, in his opinion, in lessening excessive secretion from the bron- chial surface. If the substance of the lungs be affected, a single moderate blood-letting or lo- cal depletions may be prescribed, if the patient be robust and the disease not far advanced. If the bowels be not materially disordered, anti- monials ' may afterward be given ; but they should be combined with anodynes. Ipecacu- anha, with calomel or camphor and opium, or extract of poppy, is, perhaps, preferable in most cases. Diaphoretics in frequent doses are al- ways of service, and may be conjoined with di- uretics. After depletions have been carried sufficiently far, or if the lungs are affected very late in the disease, blisters, sinapisms, or the warm terebinthinated embrocation, placed on the chest, and camphor, ammonia, ipecacuanha, or other expectorants, with hyoscyamus, or ex- tract of poppy, are the principal means we pos- sess. When in this complication the skin is cool and pale, the pulse very weak and small, and the features collapsed, the warm expecto- rants, as polygala, ammoniacum, ammonia, camphor, the stimulating tonics, and wine should be given, according to the peculiarities of the case. 549. 3. Predominant affection of the intestinal mucous surface should be treated by means sim- ilar to those advised in this complication of sy- nochus ; and the more especially, as the latter fever, when thus characterized, either passes into, or is very nearly allied to the typhoid form. In the early stages of this complication, a combination of small doses of hydrargyrum cum creta, rhubarb, and Dover's powder, with compound cretaceous powder, given every three or four hours, is generally of service. If the constitutional symptoms will permit, and if this affection appear at an early period of the fever, a local depletion should be premised, and a blister or sinapism be afterward placed upon the abdomen. The terebinthinated epithem, applied sufficiently hot, and covered so as to 152 prevent evaporation, if properly managed, is the most efficacious means, more particularly if the abdomen be tense, tender, or tympanitic. In this latter state, an injection with asafceti- da, or with the extract of rue, or with from two drachms to half an ounce of spirits of turpen- tine in addition, will give great relief. 550. In a far-advanced stage, diarrhaa, espe- cially if attended by tension, pain, or flatulent distention of the abdomen, requires great at- tention. If the medicines just recommended prove not oPservice, the chlorurets, particularly the chloruret of lime, may be given, with cam- phor, and extract of poppies, &c. Mucilagi- nous injections, containing sirup of poppies, or laudanum, or compound tincture of camphor, may also be administered, and a rubefacient epithem placed over the abdomen. If hamor- rhage from the bowels occur, it may be ascri- bed chiefly to exudation from the softened mu- cous surface, as shown by the post-mortem ap- pearances ; and acetate of lead with opium, or acetate of morphine, or extract of poppy, should be exhibited, either in the form of pill, or with the pyroligneous acetic acid in strong camphor julep. The lead has been recommended, in these cases, by Drs. Bardesley, Graves, and Stokes. I have resorted to it in these several combinations, and have given it in two or three instances with creasote. I have likewise em- ployed, by the mouth and in enemata, the spir- its of turpentine, which generally proves the most active remedy of any in such circumstan- ces. In some hopeless cases it has succeeded contrary to expectations. In one, however, that recently occurred to me, although it ar- rested the haemorrhage for a time, there was a return which carried off the patient. If the disease be far advanced, or the powers of life much reduced, the turpentine should be given in small or moderate doses, and its effects care- fully watched. I have also prescribed it in conjunction with creasote, the acetate of lead and aromatics, in similar circumstances. 551. y. Prominent affection of the brain may arise in the course of typhoid fever, either from congestion within the head, or from the de- pressed state of nervous power, unconnected with inflammatory action, or even with vascu- lar determination. This circumstance, long believed by pathologists, has been fully con- firmed by M. Louis, who found that the pres- ence or absence of delirium has little or no connexion with perceptible organic lesion of the brain. If, however, there be increased heat or severe pain of the head, spastic con- tractions of some muscles, flushed face, inject- ed eyes, or other indications of active disorder of the cerebral circulation, particularly in the stage of reaction, the hair should be removed, and local depletion resorted to. The head ought to be kept cool by cold sponging or lo- tions. If delirium be attended by these symp- toms, the same means are required ; and if it be, at the same time, low, insensible, or mut- tering, a blister should be applied to the neck and nape, or behind the ears, or to the calves of the legs, or a sinapism may be substituted in the latter situation. Whenever the affection of the head is connected with increased deter- mination to it, especially in an early stage, stimulating antispasmodics, as ammonia, musk, or camphor in large doses, cannot be of ser- 1210 FEVER, TYPHOID—Treatment or the Complications. vice, and may be injurious. The last of these, however, may be used in small doses with ni- tre, and it may be increased according to the degree of stupor and coolness of the scalp. If the delirium depend upon exhausted nervous power ; if it be attended by stupor, by a weak, soft, and very quick, or somewhat slow pulse; by a moist skin, or copious perspiration; or by extreme prostration, particularly after the eighth or tenth day, or in the nervous stage ; camphor, in doses of from one to three or four grains every two, three, or four hours ; or the preparations of valerian, or of serpentaria, or of arnica, or ammonia, or of ether, or wine, or opi- um, may be severally employed as circumstan- ces will suggest. In other respects, the treat- ment of this state, and of sopor and coma, its frequent attendants and sequents, should be directed as explained in the articles Coma (y 16, 19) and Delirium (v 16, 17). Retention of urine is very apt to occur in this state ; there- fore, in it especially, but also in all others, at- tention ought to be paid to the circumstance. If an undue accumulation of water in the blad- der be detected upon examining the hypogas- trium, it should be immediately drawn off 552. 6. In the most severe form of nervous fever (y 461) blood-letting is seldom of service, un- less at the commencement of reaction, or from the vicinity of the most affected organ. When the skin is very hot, tepid sponging, diaphoretics, external derivatives, and emollient diluents, with nitre, or small doses of the hydro-chlorate of am- monia, are the most appropriate. The infusion of valerian may be given as the disease passes into the nervous stage, either with the com- pound tincture, or with camphor, and hydro-chlo- ric ether, or other stimulants. Hildenbrand advises the arnica montana, with camphor, in this state. If exhaustion increase, and coma come on, these medicines, or others of a simi- lar kind, may be prescribed in larger doses, or at shorter intervals; and a blister applied to the vertex, or occiput, or to the nape, or a large sinapism to the epigastrium or insides of the legs. Lallemand and Mackintosh have adduced instances of benefit, in the comatose state, from pouring boiling water on the lower extremities. Musk, the ethers, preparations of cinchona, or any of the stimulants already men- tioned, may likewise be tried, in various com- binations, in this stage, or an infusion of green tea may be given in the usual manner. 553. e. If the disease be sudden in its attack, or apoplectic, care should be taken to ascertain whether or not this character arise from weak- ened nervous energy of the brain, or from vascular congestion. When a pale, collapsed countenance and eyes, weak and small pulsa- tion of the carotids, and coolness of the scalp indicate the former, restoratives will be neces- sary. But when there are increased tempera- ture of the head, and excited action of the ca- rotids, although the countenance be pale, a small or moderate blood-letting, local or gen- eral, or even a cautious repetition of it in young or robust persons, will generally be required. The same remarks equally apply to the occur- rence of paralysis. If the paralysis appear at an advanced stage, even local depletions may be injurious. In this case we must trust chief- ly to blisters and other external derivatives, and to the means already stated (y 551). 554. If in the early stage of this, or, indeed, of any other form of typhoid fever, the thirst be urgent and attended by vomiting, desire of cold fluids, and heat of skin, stimulants are generally injurious. If tenderness of the epi- gastrium accompany these, inflammatory irri- tation, or erethism of the gastro-intestinal mu- cous surface should be inferred. In this case leeches ought to be applied; and cold or iced drinks and saline medicines, particularly the ni- trate of potash or the hydro-chlorate of ammonia, frequently exhibited. A combination of cam- phor mixture, the solution of the acetate of ammonia, nitrate of potash, and spirits of nitric ether, will generally be serviceable in these circumstances. Effervescing draughts are pro- ductive of little benefit, as the extrication of fixed air distends the stomach, and either caus- es it to react upon and throw off its contents, or gives rise to much distress and pain. If ir- ritability of the stomach still continue, a large blister may be applied over the epigastrium. Dr. Stokes advises, in the more obstinate ca- ses, the raw surface to be sprinkled with a small quantity of the acetate of morphia. I have rarely found the warm turpentine embrocation fail of removing this state of disorder when properly employed. 555. f. When singultus occurs in the stage of reaction, it is generally connected with the foregoing state of the stomach, and particular- ly with irritation about the cardiac orifice. In this state the treatment just advised is the most appropriate. When it appears in the ner- vous period, or later, it depends upon exhaust- ed nervous energy, and requires stimulants, antispasmodics, and anodynes. Camphor, am- monia, the ethers, musk, valerian, opium, and their preparations, variously combined, are the most serviceable. 556. n. Diarrhcea is one of the most frequent precursors of disease of the intestinal mucous follicles ; yet should it not be rashly interfered with, and still less abruptly arrested, particu- larly when it occur early, or at a critical period. I have imputed the affection of the intestinal mucous surface in great part to the morbid condition of the blood ; this surface being one of the channels by which effete, or injurious materials, pass out of the circulation during the course of fever. It is evident, therefore, that if we shut it up without opening othere, the alterations of the blood will increase, and occasion serious organic changes, and ultimate- ly a fatal issue. The most rational procedure, when diarrhcea is an early complication, is not to interfere with it, unless it become severe or continue long, and then it should be moderated rather than arrested, and by such means as will increase the depurating functions of the skin, the kidneys, and liver, and remove the irritation excited in the digestive mucous sur- face and follicles. The remedies most likely to produce these effects are actually those which have been found most serviceable in this state of disease. Hydrargyrum cum creta, compound ipecacuanha powder, camphor, nitre, mild anodynes, variously combined with de- mulcents, emollients, and diluents, are the most generally of service. In more advanced states of this complication, and in later stages of fever, those medicines which have been al- ready noticed (y 156), as well as some about to f FEVER, TYPHOID—Treatment of Putro-adynamic. 1211 be mentioned, may be resorted to. When the | pulse is small, very frequent, and weak, and the strength exhausted, diarrhoea must then be arrested, otherwise it will speedily terminate life. Astringents, opiates, absorbents, restora- tives, wine, &c., are all requisite in this case. 557. 0. Tympanitic distention of the abdomen may occur early in this fever, and be attended by thirst, by a desire of warm diluents, by ten- derness on pressure, particularly in the lower part of the right side of the abdomen, and by diarrhoea. When these symptoms are present, disease of the intestinal mucous follicles may be inferred. In this case a number of leeches, according to the strength of the patient and stage of the fever, should be applied, and fol- lowed by the warm turpentine embrocation on the abdomen. If tympanitis and diarrhcea ap- pear late in the disease—particularly if the stools be foul, watery, or mucous—ulceration of the intestinal surface should be dreaded, and the means already advised (y 156) should be resorted to, or the chlorurets given in the in- fusion of valerian, or in emollient vehicles, with camphor, anodynes, &c. From one or two to four or five drachms of spirits of turpentine may be prescribed once or twice, or even oft- ener in some cases, in a suitable vehicle, if these fail; or this substance, or asafoetida, or extract of rue, with some anodyne, may also be administered in mucilaginous enemata from time to time. In most cases of flatulent dis- tention of the intestines, there is great dispo- sition to ulceration of the aggregated mucous follicles—if, indeed, it has not already com- menced—and both morbid conditions are great- ly aggravated by the continuance of the flatu- lent state. The intention, therefore, is to pro- cure the discharge of flatus by means which may, at the same time, sheath and soothe the irritable mucous surface, and restore the lost tone of the capillaries of the diseased part; and whatever operates in this way will be produc- tive of benefit. It is only by a judicious com- bination of agents that this effect can be at- tained ; and those just mentioned seem the most efficient, especially when the skin is cool, the pulse feeble, and the prostration extreme ; and, in this state, the more energetic stimu- lants and tonics, or wine, or opium, may also be employed, according to the peculiarities of the case. (See y 155-159.) 558. i. The occurrence of perforation of the intestines, and consequent peritonitis, should not be overlooked in the enteric complication, or other severe forms of low nervous fever. Per- itonitis seldom arises except from this cause, for large patches of the mucous surface, with Peyer's glands, may be destroyed by ulcera- tion ; and yet the peritoneum will be unchanged. When, however, diarrhoea has been suddenly arrested early in the disease by an injudicious use of astringents, general peritonitis and effu- sion may result without perforation, and even without ulceration. But this is only one of several bad consequences which may proceed from injudicious interference. If, in an ad- vanced stage of fever, and after thirst, diar- rhcea, tympanitis, and great prostration of strength, the patient suddenly complain of pain in some part of the abdomen, extending over it, with tenderness, increased distention, and rapid sinking of the powers of life, peritonitis has occurred. In this case large doses of opi- um, to palliate the patient's sufferings, are the only means that can be used with any benefit. Dr. Stokes, who has very ably elucidated the subject of peritonitis from this cause, and its treatment, directs one grain of opium to be giv- en every hour, or two hours, until a decided effect is produced by it; and afterward at long- er intervals. (Dublin Hosp. Rep., vol. v.; and Dublin Jour, of Med., vol. i., p. 125). When ef- fusion of the intestinal contents into the perito- neal cavity occurs, the result must be fatal. But when adhesion of the peritoneum to the opposite surface takes place previously to the perforation, or when the perforation is speedily followed by a limited inflammation and effusion of lymph, recovery is possible. The formation of coagulable lymph can hardly, however, be expected in peritonitis occurring in the course of fever, as the slates of vital action and of the circulating fluids are generally incapable of pro- ducing it. 559. b. Treatment of Putro-adynamic Fever (y 472).—The phenomena which especially char- acterize this variety may appear either at an early stage of fever or at an advanced period; they may be the concomitants, or early conse- quences of depressed vital energy, and imper- fect powers of reaction ; or the results of vas- cular reaction being so great, relatively to the state of vital influence, as to exhaust both the irritability of contractile parts, and the tone of the extreme vessels. In either case, altera- tions of the circulating fluids, and deficient vi- tal cohesion of the soft solids speedily follow, and coexist with these changes. In conformi- ty with this view, with the pathological facts stated above (y 523), with a recognition of the characters of epidemics which have been ob- served in modern times in different countries, and with the results of personal observation, it may be safely inferred that the treatment of this fever should mainly depend upon the state of vital action early in the stage of excitement, and the period of the disease in which the pu- tro-adynamic signs appear ; and that, in a prac- tical point of view, it will be, therefore, advan- tageous to divide this variety of typhoid fever into, 1st. The consecutive putro-adynamic, or that form which is contingent on more or less man- ifest reaction ; and, 2d. The primary putro-ady- namic, or that which is attended by imperfect, or no reaction, and in which the characteristic phenomena appear early in the disease. It should, however, be recollected that both these forms may occur in the same epidemic, or that either may predominate; and, moreover, that the first or contingent state of putro-adynamia is sometimes met with in all epidemics, wheth- er the fever be common synochoid, typhoid, or exanthematous, owing to the causes stated above, and with a frequency relative to the prevalence of these causes (y 502-504). 560. a. The stages of premonition and of inva- sion of this variety are scarcely different in their characters from those announcing ner- vous or typhus fever. The same means as have been advised above (y 543) may, there- fore, be resorted to, with the intention of pre- venting the farther progress of disease, or of rendering it more mild. When the symptoms of invasion are either indistinct or protracted, the consequent fever is often rendered much 1212 FEVER, TYPHOID—with Putro-adynamia—Treatment. less dangerous than it otherwise might have been, by the adoption of the measures already detailed, and more particularly by exhibiting an energetic emetic, and by promoting its full operation by warm or tepid mucilaginous dilu- ents. Tepid sea water, or a weak solution of common salt in a tepid state, has been employ- ed with advantage for the purpose either of promoting the action of the emetic, or of pro- ducing full vomiting when there has been nau- sea or sickness. 561. 3. In the consecutive putro-adynamic, or when the stage of excitement is more or less de- veloped ; when the pulse is frequent, full, or sharp ; the skin hot, and thirst considerable, or if an internal heat be felt, vascular depletion may be practised, but with due reference to the circumstances of the patient, and to the period which has elapsed from the time of invasion. So long as the characters of putro-adynamia have not appeared, these symptoms fully war- rant a cautious recourse to depletion; and in young, robust persons even a repetition of it. If rigours and shiverings are followed by inor- dinate or tumultuous reaction, the necessity of larger depletions is obvious. But, even in this case, they should not be carried too far, or to the extent of producing syncope ; otherwise, in attempting to avoid the exhaustion conse- quent upon excessive action, a quantity of blood may be withdrawn too great for the diminished power of tonic contraction possessed by the blood-vessels, the vessels being incapable, ow- ing to the loss of their tone, to accommodate themselves to, or contract sufficiently upon their contents, when the reduction of these contents is great—and thus collapse of vascu- lar action, and of vital power, may follow. 562. y. In the primary putro-adynamic, or in cases attended by indistinct signs of invasion, and by imperfect reaction, we can hardly ven- ture upon depletion, unless indications of con- gestion or prominent affection of an important organ present themselves. In this instance, local depletions or dry cupping may be tried. If petechiae appear early in these cases, or if the pulse be very compressible, very small, or broad and open; if the skin be cool, damp, or unnatural, yet not hot; if the tongue be flabby or covered by a dirty mucus, although the fe- ver is evidently not far advanced, or is very re- cently passed the stage of invasion, then bleed- ing should not be attempted. In this case very different means must be employed; and with an energy proportionate to the prostration of strength attending these symptoms. If pete- chia;, or vibices, or blotches have appeared on the skin, they will furnish an additional indica- tion, particularly if they assume a dun, or dark, or livid colour, and will indicate the propriety of having recourse to the tonics, stimulants, and antiseptics, and the combinations of them about to be noticed. 563. d. In either form of this fever—in the first, after depletions; in the second, after the operation of an emetic, which should be given at any time during the invasion, or for three or four days afterward—the bowels ought to be freely evacuated by either of the mild purga- tives mentioned above, and by the occasional use of laxative enemata ; and frequent but small doses of nitre may be afterward exhibited in the saline medicine already prescribed, or of the hydrochlorate of ammonia in camphor mix- ture, or any other suitable vehicle. These lat- ter are more especially indicated if any heat is felt in the region of the stomach, and if the tongue is red at its edges and point. If there be increased heat of skin, tepid sponging the surface with the weak nitro-hydrochloric solu- tion, or with a mixture of pyroligneous acetic acid, rose-water, and camphor mixture will prove both grateful and beneficial. It is sel- dom, even in the primary putro-adynamic, that tonics are productive of much benefit very ear- ly in the disease. But, when exhibited with refrigerants, they are often of great service. The infusion or the decoction of cinchona, ei- ther with the solution of the acetate of ammo- nia and nitrate of potash, or with the hydro- chlorate of ammonia, a few drops of hydrochlo- ric acid, and sometimes also with hydrochloric ether, is the kind of tonic which I can recom- mend from experience as being the most suit- able to an early stage of adynamic fever. 564. It is in this variety of typhoid fever, more especially, that the question as to the su- perior efficacy of alkaline medicines and of the non-purgative salines, or of mineral and vege- table acids, becomes a matter -of extreme im- portance. Of the latter I can speak from ob- servation ; of the former I have not yet made sufficient trial to enable me to form a satisfac- tory opinion. It were to be desired that Dr. Stevens, who has so strongly advocated the use of alkaline and saline substances in this fe- ver, would furnish us with that sort of evi- dence of their efficacy which would justify an early and decided recourse to them; and that those who have ample means furnished them of settling the question at issue would at last put it beyond the reach of cavil. That these substances are beneficial, at least several of them, is fully shown by the experience of suc- cessive ages and of numerous writers. This is the case in respect of nitre, hydrochlorate of ammonia, and chlorate of potash, of the excel- lent effects of which I am convinced by repeat- ed observation. But the superiority of alkaline carbonates over acids has not yet been proved. It is also doubtful whether or not the benefit found to result from the former has not chiefly proceeded from the medicines with which they have been combined. At present we are guided, in some measure, by what we know of the phys- iological action of these substances. The fix- ed alkaline bi-carbonates redden the blood when carried into it, but they relax the tone of the digestive mucous surface. Nitre produces a similar change in the blood, and resists any tendency to decomposition. Acids constringe the mucous and contractile tissues, impart firm- ness to the coagulum, but render the blood more dark than natural. With these imperfect data, the experience derived from accurate ob- servation ought to be our chief guide; and whether we adopt acids in the earlier stages of the disease, and alkalies subsequently, or reverse this order, or even prescribe, in con- junction with neutral salts, either an acid or an alkali in excess, much difficulty will be felt in ascertaining how much is due to either of these means, and what may be legitimately imputed to other remedies, with which we may be mor ally bound to combine them in order to render their beneficial operation more certain. W hen FEVER, TYPHOID—with Putro-adynamia—Treatment 1213 certain remedies, which have been particular- ly recommended in this form of fever, come under review, these substances will receive farther attention. 565. In various states of putro-adynamic fe- ver, external derivatives will be required, as in the other varieties. When blood-letting is ne- cessary at the commencement, they should fol- low this operation, particularly when promi- nent affection of an important organ exists. As to the choice of derivatives, little need be added to what has been already advanced. If blisters be adopted, attention is sometimes re- quired to prevent spreading or sphacelating sores. They should, therefore, be applied only until they cause redness of the surface, when they may be followed by a warm poultice. Equal care is necessary to prevent sphacela- tion of the parts pressed upon in bed, and the occurrence of foul sores from the contact of the morbid excretions, or from both causes conjoin- ed. The means likely to counteract or remedy this occurrence have been stated above (y 166). 566. e. In the modifications of this fever, no- ticed above (y 476), a decided recourse to the same medicines as are necessary in the ad- vanced stages of the regular form must be had, more particularly when signs of colliquation are early and prominent. The intention in this case is to arrest the progress of the changes of the blood, by supporting the powers of life, and promoting the functions of excretion. If it should be found possible to correct in a more direct manner the state of the circulating flu- ids, this indication ought also to be adopted, and the means which operate in this way re- sorted to. In conformity with the former indi- cation, full vomiting should be induced, if it have not already taken place, and a mild sto- machic purgative afterward given. This latter ought to be repeated according to the state of the bowels, and the appearance of the evacua- tions, which will furnish indications for the em- ployment also of enemata, and indicate such as are most appropriate. In the worst forms of erysipelas, and in diffusive inflammation of cellular structures, I have found equal parts of the decoction of cinchona, and the compound infusion of senna, with tartrate of potash, car- bonate of soda, and compound tincture of car- damoms, an excellent purgative, and I see no reason against its use in this state of adynamic fever. After the bowels have been freely evac- uated, decoction of cinchona, or a strong infu- sion of valerian, with chlorate of potash, and chloric ether, may be prescribed, according to the severity of the disease. Of the good ef- fects of the decoction of cinchona with the compound tincture, nitrate of potash, and car- bonate of soda, I can also speak from expe- rience. When the prostration of strength is extreme, a pill containing two or three grains of camphor should be taken with each dose of either of these, at short intervals. 567. Other tonics, and different combinations of them from these now mentioned, will fre- quently be productive of great benefit, when morbid excretions have been evacuated. How- ever specious the arguments adduced by some writers against the employment of acids in the putro-adynamic states of fever, it cannot be denied that good effects have been produced by them, especially when exhibited with pow- erful tonics. The infusion or decoction of cin- chona, with hydrochloric acid, or with nitro- hydrochloric acids, and chloric ether (formerly Clutton's febrifuge); the sulphate of quinine with sulphuric acid, and Hoffmann's anodyne ; and pyroligneous acid in large doses, with camphor, the solution of the acetate of ammo- nia, and tonic or aromatic infusions, or the in- fusion of serpentaria or of arnica, are the most energetic, and may severally be tried, accord- ing to the peculiarities of the case. A solution of camphor in acetic acid was a favourite medi- cine with many writers on putro-adynamic fe- ver, and was employed by them both internally and externally. 568. Dr. Stevens's saline treatment is most appropriate in this form of fever. He directs twenty grains of the chloride of sodium, thirty grains of the carbonate of soda, and eight of the chlorate of potash to be given every two or three hours—or more or less frequently ac- cording to the urgency of the case—dissolved in water, in the advanced stages. He believes that, when these salts are prescribed before the stomach has ceased to perform its functions, they will not irritate the alimentary canal, but will be absorbed into the circulation and correct its morbid state. One or two table-spoonfuls of common salt may also be administered oc- casionally in a tepid gruel enema. The strength should, at the same time, be supported by strong beef tea, or the regimen about to be recom- mended. 569. f. If putro-adynamic fever be attended by predominant affection of any organ, local de- pletions, followed by external derivatives, will be necessary, particularly in an early stage of the fever. At a later period, external deriva- tion, and the other means advised for the com- plications of nervous fever, according to their seat, should be employed. In this variety, however, a more liberal use of tonics, conjoined with the antiseptics just mentioned, is gener- ally required. When this or any other form of typhoid fever is complicated with asthenic inflammation of the fauces or pharynx, or both, the means already recommended are quite ap- propriate. In these cases, deglutition is very difficult, and sometimes impossible. Recourse to external derivatives and to injections is then urgently required. The action of the bowels should also be solicited by purgative enemata, unless diarrhcea exist; and the medi- cines that are indicated should be administered in clysters, and in sufficiently large doses. As the patient is generally unable to gargle his throat, advantage will sometimes accrue from syringing it with any of the tonic mixtures above prescribed, or with a solution of the chloruret of lime or of creasote ; and if a part, or the whole, or either of these should be swal- lowed, the more benefit will be derived. 570. tj. If this variety become complicated with diarrhcea, disorganization of the digestive mucous follicles and surface will rapidly take place, if the treatment be not prompt and judi- cious. The means already advised (y 549, 550) for this complication must be adopted in this case. If the diarrhcea occurs at an early period, it will generally be moderated by tonic infusions, with the nitrate of potash, or with the hydro- chlorate of ammonia, and the compound tincture of camphor. A combination of ipecacuanha, ni- 1214 FEVER, TYPHOID—Exanthematous—Treatment. tre, camphor, and opium, or extract of poppy, will also often diminish or remove it. If hamor- rhage supervene from the bowels, these medi- cines will sometimes be sufficient to remove it In more urgent cases, the energetic remedies previously directed (y 550), or the pyroligneous acetic acid, with camphor and creasote, or tur- pentine, &.C., should be prescribed by the mouth, and in enemata. ^*hen diarrhoea or haemor- rhage characterizes putro-adynamic fever, the alkaline carbonates will frequently aggravate or perpetuate it, and render convalescence pro- tracted. In other respects, the treatment di- rected for the complications of nervous fever, and for its last stages, is also suitable to this ; these stages requiring either the measures just described, or several of those about to be noticed, with a more or less direct reference to the putro-adynamic state, or various com- binations of the substances already enumera- ted (y 548-555). 571. c. Treatment of exanthematous Typhus (y 485).—The premonitory and invading periods of this fever should be treated as recommended above (y 543), with the view of arresting or rendering more mild the procession of morbid phenomena.—a. In the stage of reaction the in- dications are, (a) to moderate excessive ex- citement ; (b) to guard important organs from the effects of prominent action. If full vomit- ing has not occurred previously, it should be excited by an emetic at the commencement of this stage, or on the first, second, or third day of it. If, however, inflammatory signs have become evident, particularly if the lungs are affected, a moderate blood-letting should pre- cede the emetic. The eruption, which gener- ally appears in this period, is usually followed by slight alleviation of the symptoms, and should therefore be promoted by mild, tepid diluents, which may be made either diaphoret- ic, mucilaginous, or acidulous, according to cir- cumstances. As to blood-letting, in this disease it is pernicious in many, if not in most cases; and not merely in the nervous, but even in this stage. In the mild and regular typhus it is superfluous; but when a highly inflammatory character marks this period, or when local ac- tion becomes very prominent or excessive, it must not be omitted, otherwise the local affec- tion may run into disorganization, and the ner- vous stage will be rendered more protracted or dangerous. The amount, repetition, and mode of depletion will depend upon the peculiarities of the case. When the bowels are open in this stage, purgatives, unless of the mildest kind, are unnecessary. Severe purging is prej- udicial, as it derives from the skin, interrupts the regular course of the disease, and risks the production of the enteric complication. Tonics and stimulants are also injurious. 572. B. In the nervous stage the disease has induced a state of exhaustion, and the system requires to be supported, and even gently ex- cited. Hildenbrand recommends an emetic early in this period, if it have not been given previously ; and blisters to be applied about the seventh or eighth day, when the nervous stage commences. Camphor, with the solution of the acetate of ammonia and nitre, forms one of the best medicines that can now be exhibited. The quantity of camphor, however, should not, at first, exceed one grain every two hours, or a grain and a half every three hours. Arnica. was one of the medicines most commonly em- ployed in Germany during the prevalence of this fever in that country early in the present century. Hildenbrand states that its opera- tion is stimulant, alterative, and, in large doses, emetic; and that it does not promote, but rather prevents diarrhoea. In typhus it lessens the stupor, giddiness, and delirium, and in- creases the cutaneous transpiration; but it is useful only when the inflammatory character is quite gone. It should be given in the form of infusion, in a quantity short of producing nausea. This most able and experienced wri- ter advises also, in the course of this stage, the use of volatile stimulants, especially the in- fusions of the roots of angelica and imperatoria, and of the flowers of the calamus aromaticus. 573. In the typhus epidemic, in the military hospitals in Vienna and surrounding countries, during the late war, where it was impossible to prescribe for the cases individually, the follow- ing plan was pursued by Hildenbrand with great success in the simple and regular dis- ease : On the first day of the fever an emetic was administered, and succeeded by diluent diaphoretic decoctions. About the seventh day, when the typhomania and debility were increased, the skin and tongue dry, and the belly distended, blisters were put upon the calves of the legs, and eight ounces of an infu- sion of two drachms of the flowers of arnica, and as much angelica root, with a little of Hoffmann's anodyne, were given daily, two table-spoonfuls being taken every two hours, alternately with camphor powders. Stimu- lants, in this fever, should be prescribed in fre- quent but small doses, rather than in large quantities. Cinchona and other tonics are su- perfluous as long as the disease is mild and regular. But they, together with wine, &c, are required if the putro-adynamic state ap- pears in this stage. 574. y. If the preceding stages have been prudently treated, and if the disease has been regular and mild, nothing more is necessary in the way of medicine, as the period of crisis ap- proaches, than to promote the evacuations at- tending it; and. as the chief of these is perspi- ration, mild diluents, and the diaphoretics in common use, or those just mentioned, are to be continued. All medicines should not be abandoned immediately after a crisis. Stimu- lants, however, should be milder, and given at longer intervals. Hildenbrand advises the camphor and arnica to be given up, and the in- fusion of angelica to be continued for some time. As convalescence advances, the treatment should be chiefly dietetic and regimenal. 575. 6. The irregular forms of typhus—the modifications and complications—require ap- propriate means, or variations of the procedure now recommended. If the inflammatory charac- ter is violent, a more active antiphlogistic treat- ment is necessary. But the existence of defi- cient power, and the knowledge that the ner- vous stage must follow, should influence the practitioner. For an inflammatory state of the brain, or the semi-apoplectic state, bleeding generally and locally must be adopted, to an amount which the circumstances of the case will suggest. When the lungs are affected, this practice, aided by antimonials, blisters, and FEVER, TYPHOID—Certain Medicines in. 1215 diaphoretics, is equally necessary. If the in- flammatory state be not entirely removed, and if it is not safe to bleed more, or if this state be prolonged into the nervous stage, external de- rivatives and antimonials are to be chiefly con- fided in. The same practice is applicable to the association of hepatic disease in this stage. The affection of the intestinal mucous surface requires the same treatment as was recom- mended in synochoid and nervous fevers (y 549, et seq.). Sometimes the gastric or bilious char- acter predominates, particularly in summer and autumn, owing to impurities in the prima via, and accumulations of bile in the hepatic ducts and gall-bladder. Emetics are necessary in these cases especially, unless there are indica- tions which forbid them ; and mild purgatives, in the inflammatory stage — in the nervous, aperient clysters—should be preferred. 576. e. In the nervous stage various irregu- larities often occur. If this character is exces- sive, or has taken place suddenly, large and repeated doses of volatile stimulants are neces- sary. Camphor, ammonia, ether, musk, cin- chona, serpentaria, wine, opium, and blisters are severally useful, when judiciously combined. Phosphorus has been recommended for this state, but Hildenbrand found it useless. During this stage, a passive, asthenic, or nervous kind of inflammatory action may occur, particularly in the mucous surface of the intestines and in the mucous follicles ; but it sometimes also af- fects the brain and lungs. When it attacks the intestines, there is a painful feeling excited by pressing the abdomen ; the pulse is small and irregular or unequal; the belly is tympanitic or tense, and the stools very frequent and morbid. For this state, a moderate or small local deple- tion ; blisters, sinapisms, or hot turpentine em- brocations, followed by warm poultices over the abdomen ; camphor, with hydrargyrum cum creta, and Dover's powder, in large quantities of mucilage; or camphor with ipecacuanha, nitre, and opium; mucilaginous enemata, with extract of poppies, &c.; and the other means already mentioned (y 550), should be chiefly re- lied upon. If this form of inflammation, or of inflammatory congestion, attack the liver, ten- derness and fulness in the right hypochondrium, and jaundice generally accompany it, and a very dangerous complication results. Local depletion is sometimes of use, but as frequent- ly it is of little service. Mercurials, excepting, perhaps, the hydrargyrum cum creta, are still less efficacious. Blisters over the hypochon- drium and epigastrium; frictions with rubefa- cient liniments in this situation; rubefacient applications on the insides of the thighs ; emoll- ient and aperient enemata, if the bowels require to be assisted; camphor, with nitre or sulphate of potash, and anodynes ; diuretics conjoined with mild diaphoretics ; and the nitro-hydro- chloric acid given internally with the spirits of nitric ether, or used externally as a lotion or wash, may severally be productive of benefit. 577. f. The nervous inflammation of the brain is indicated by sopor and profound typho- mania, and should be combated by blisters on the head, by camphor, by arnica, and the means directed for this affection in nervous fever (-) 551). If tightness of the chest and dyspnoea occur in the nervous stage, congestion of the weakened vessels of the lungs may be inferred. In this state a small bleeding, to the amount of four or six ounces, may be directed in some cases, and followed in all by blisters on the chest, and antimonials conjoined with camphor. 578. y. If the putro-adynamic character super- venes and predominates as the nervous stage proceeds, the debility, equally with the morbid state of the blood, requires attention. The preparations of cinchona, either with mineral acid, or with alterative neutral salts, large doses of camphor, wine, opium, and the other means directed for the various phases and complications of this condition, will be required, according to the peculiarities of individual ca- ses. If diarrhoea or dysentery comes on in this state, opium in large doses, but at distant in- tervals ; warm dilute wine, with spices and other aromatics; mucilaginous and farinaceous liquids, or gruel with common salt, taken in small quantities, but often, and administered in enemata, with sirup or extract of poppies ; and the other remedies noticed above (y 556), should be prescribed. If singultus or meteorismus oc- cur, they should be treated conformably with the principles already explained (y 557). Swell- ings of the parotids are unpleasant accidents, even when critical. They should be checked, at first, by keeping the bowels moderately open, and cold applications to them. If this end be not accomplished, then suppuration should be promoted by stimulating poultices; and the ab- scess should be early opened, in order to pre- vent contamination of the surrounding cellular parts. If gangrenous sores appear in any part, the means directed above (y 166), more partic- ularly the chlorides, creasote, powdered bark, turpentine, &c, either severally, or variously combined, or in the form of wash, epithem, or poultice, ought to be promptly and assiduously employed. 579. iii. Of certain Medicines, Sf-c, in Typhoid Fevers.—a. Antimonials, especially James's pow- der and tartar emetic, are frequently of service in the early stages of fever ; the latter for its emetic operation, and its febrifuge or contra- stimulant action during excitement; and the former for this last effect, in connexion with its diaphoretic influence. The remarks already offered respecting these medicines (y 162) are applicable to the use of them in the fevers under consideration. It is chiefly in the early periods, in the more inflammatory states, in the pulmonary complications, and either in aid of, or as substitutes for blood-letting, that they should be employed, more particularly the po- tassio-tartrate of antimony. However, the re- sults of Rasori's practice, and the recent trials made of this medicine by Dr. Graves in the advanced stage of typhus, indicate the propriety of having recourse to it, at a later period, in much more liberal doses than have been hith- erto considered safe. This able physician, rea- soning from the good effects of the medicine in delirium tremens, was induced to resort to it in a case presenting a quick, failing pulse; a black, dry, tremulous tongue ; tympanitis ; low, mut- tering delirium ; startings of the tendons, and nervous agitation. He prescribed four grains of tartar emetic in eight ounces of camphor julep, with a drachm of tincture of opium—a table-spoonful to be taken every second hour. The patient vomited after the second dose ; and, after the fourth, he fell into a calm sleep, 1216 FEVER, TYPHOID—Certain Medicines in. and soon recovered. Besides the good effect of this medicine, that of vomiting at this stage of fever, as recommended by many of the older writers, is shown by this case. Dr. Graves refers to other instances (Lond. Med. and Surg. Journ., vol. vii., p. 541) in which tartar emetic and opium produced decided benefit in most unfavourable states of the advanced periods of low nervous fever, and of exanthematic typhus. The combination of the potassio-tar- trate of antimony with nitre is most appropri- ate in the stage of excitement; but, in the ner- vous stage, opium seems indispensable to the good effects of the antimony. 580. b. Of other antiphlogistic and contra-stim- ulant means, it is unnecessary to add anything to what has been already advanced. The con- tradictory opinions entertained as to the pro- priety or amount of depletion are readily ex- plained, when the various forms of typhoid fever, and circumstances of the case, are taken into consideration, in connexion with the in- tentions with which blood-letting on the one hand, and restoratives on the other, are resort- ed to ; and with the fact that both are very frequently required, not only consecutively, but even simultaneously. This circumstance was well known to very many of the numerous wri- ters on these fevers during the last three cen- turies, both in this and in foreign countries. They well knew and strenuously inculcated the fact, even as late as the days of Clarke, that, in order to prevent the accession of the putro- adynamic state, it is necessary to bleed, and to use other antiphlogistic remedies with decision, early in various fevers and epidemics. And, next to bleeding, nitre and the hydrochlorate of ammonia were held in estimation, for their ef- fects in lowering morbid reaction at the com- mencement of typhoid fevers, and in prevent- ing putridity in advanced stages. Thus, while nitre was conjoined with antimonials, ipecac- uanha, small doses of camphor, or with the spirits of nitric ether, to fulfil the former inten- tion, and to promote perspiration and the ac- tion of the kidneys, it was given with tonics and stimulants, to produce the latter indication. The writings of Delius, Hillary, Haenel, Wood, Rasori, and many others show us how very little we have hitherto improved upon their practice in these fevers. The same re- mark applies to the use of the hydrochlorate of ammonia, whose operation as a refrigerant antiseptic and tonic ranks it as one of the best and most generally applicable of the many remedies employed in fever. 581. c. As to the use of alvine evacuations, we have arrived at similar conclusions to those very generally acted upon during the seven- teenth and eighteenth centuries, but partially lost sight of towards the close of the latter. The good effects of emetics at the commence- ment of typhoid fevers were almost universally admitted, until Broussais banished them from his code of therapeutics. That circumstances sometimes occur which either render them unnecessary, or even forbid them altogether, has been allowed ; but very sufficient evidence has been adduced of their good effects, more particularly in the periods of premonition and invasion, and even early in that of excitement. Many writers of great experience, especially Cheyne, Tuomy, Stoll, Sandiford, Reil, Hil- denbrand, Hufeland, &e, have advised them in the advanced stages of these fevers ; and although they are rarely employed in these periods by practitioners in this country, I be- lieve that they will often prove of service even then, when judiciously resorted to, in exan- thematic typhus. The injurious effects impu- ted to them by Marcus, Wendelstadt, Brous- sais, and others are to be referred to the em- ployment of them in the gastric complication, and in other circumstances which contra-indi- cate their use. 582. The operation of purgatives in low fevers is now well understood; the indiscriminate use of them encouraged by the writings of Hamilton having been checked and tempered by the partial adoption of the views of Brous- sais. And yet I believe that the particular state of the intestinal mucous surface that ex- ists in these fevers may be increased by a neg- lect of this class of medicines ; and that, when appropriately combined, many of them are cal- culated to prevent, or to alleviate the morbid condition which the disciples of Broussais im- agine them to produce. A tolerably active purgative early in excitement, or in the other circumstances above noticed, both lowers ex- cessive action and removes morbid excretions, which, if allowed to remain, would prove a cause of irritation and contamination to the frame. In cases, however, where the vascular excitement is attended by vital prostration, either early or late in the disease, the use of purgatives requires much caution. When ex- citement is considerable, calomel with jalap, or with rhubarb, will be given, at first, with advan- tage ; but, in other circumstances, the calomel should be withheld. When, with excitement, there is considerable pulmonary affection, the potassio-tartrate of antimony may be added to the purgative adopted, as advised by Dr. M'Cor- mac, and, indeed, very generally adopted in practice. But when vital depression is the predominant feature of the disease, we should be as cautious in the use of purgatives as in having recourse to bleeding. The evacuation of the serous portion of the blood by means of the former is nearly equally depressing with the latter operation. In the advanced stages, and especially when putro-adynamic signs be- gin to appear, the blood-vessels, owing to the loss of a great portion of their tonic contractil- ity, cannot accommodate themselves to the evacuation of much of their contents, in what- ever way it may be effected; for the column of blood in the vessels is no longer presented to the contraction of the ventricles in that state of tension which favours its healthy cir- culation. If the bowels, however, require the aid of a purgative during a stale of prostration, it ought not to be withheld ; but it should be so selected as to produce no greater evacuation than may appear requisite, and be so combined as to leave a tonic or salutary impression upon the digestive mucous surface. In such cases, equal parts of the compound infusions of gen- tian and senna, or an infusion of cinchona and rhubarb, or the compound decoction of aloes, or rhubarb and carbonate of soda, or the pur- gatives already mentioned (v 150,151), or some of those prescribed in the Appendix (F 180, 181, 205, 216, 252, 433), may be resorted to. In the putro-adynamic form, and in the advanced FEVER, TYPHOID—Certain Medicines in. 1217 states of typhoid fever, purgatives ought to be always combined with tonics and aromatics. They should never be given excepting very manifestly required, and then in moderate doses, and combined as now advised, particu- larly when there is diarrhoea, or evacuations of blood, or meteorismus. However, rhubarb, or turpentine, in small or moderate doses, with aromatics, will often be of much service in such cases. 583. d. There are several stimulants of great use in low fevers; and which, owing to their peculiar or febrifuge operation, may be given with great benefit in that state of excitement which is attended by vital prostration, as well as in more advanced stages of the disease. Of these the most applicable and beneficial is camphor. This substance is most generally adopted, and has received the encomiums of most writers on typhoid fevers, and more par- ticularly of Riverius, Stoll, Ferro, Home, Marcus, Thomann, Gebel, Reil, Schlegel, Horn, and Hildenbrand. I have prescribed it not only in these, but also in pestilential, exan- thematic, puerperal, and common continued fevers ; and am satisfied as to its good effects, either when exhibited alone or when combined with other appropriate medicines, and given in proper doses. In the stage of excitement, the dose, and the medicines which should be asso- ciated with it, should have reference to the state of vital power, to the mildness or severity of the disease, and to the nature of the promi- nent affection or complication. In this stage, particularly if vital power is not much lowered, it may be given in frequent doses of half a grain, or a grain, with a weak solution of the acetate of ammonia, or in a mixture with it and spirits of nitric ether, or with nitre (F. 494, 496), or with hydrochlorate of ammonia (F. 431), or with antimonials (F. 493), or with any two or more of these. It may be also exhibited in some circumstances with advantage conjoined with calomel. If vital power is much depressed in this stage, the dose of the camphor may be increased, and the antimonial or the calomel omitted, or given merely at the outset. In some one or other of these combinations, it will prove of benefit, whatever complications the fever may present. As the disease passes into the nervous stage, and more especially as this stage passes into extreme exhaustion, the dose of camphor should be increased, and it may then be conjoined with tonics, various stimulants, antiseptics, &c, as arnica, cinchona, serpentaria, valerian, angelica, opium, sulphate of quinine, the chlorides, musk, aromatics, &c, according to the period and peculiarities of the disease. Many of the best writers in Germany prescribe it, early in the nervous stage, with arnica, or with acetic or citric acid. Haute- sierk, Callisen, Ludwig, Bonnevault, Frank, Jaegerschmidt, and Hufeland direct a solution of camphor in acetic acid to be taken internally, and used externally, early in most states of typhoid fever. With the pyroligneous acetic acid, the camphor may be conjoined with still greater benefit. The inflammatory state of any organ, supervening in the course of typhoid fevers, does not contra-indicate the use of camphor, if given appropriately to the degree nf vascular action and of vital power. 584. Arnica has been very much employed 153 in Germany in low fevers, and in the nervous stage of typhus, yet it has not received a sat- isfactory trial in England nor in France. Stoll, Fischer, Collin, Ferro, Mercier, Frank, Richter, Hecker, Hildenbrand, and other high authorities recommend it generally, as di- rected above (v 572). Quentin prescribes an infusion of it with valerian. The flowers and the root are most commonly employed, and usually in the form of a weak infusion (F. 222, 223). 585. In the low nervous form of typhoid fe- ver, as well as in the nervous stage of exan- thematic typhus, or in that stage and state of the disease for which the German physicians prescribe arnica, valerian maybe employed with advantage. Matth.ei, Frize, Reil, Thomann, and others recommend it. I have given an in- fusion of it in several cases, and made it the vehicle of other medicines, particularly the chlorate of potash, camphor, the alkaline car- bonates, serpentaria (F. 269, 270), &c. It is in- dicated in such states of fever as require a gen- tle tonic and stimulant of the nervous influ- ence, especially when the nervous symptoms are predominant, although the head be cool and the pulse weak. In these circumstances it may be conjoined with camphor, tonics, &c. 586. Serpentaria root was praised by Fribev Stoll, Reil, Marcus, and others in the advan* ced stage of low fevers, and in the circumslaiir ces just mentioned. It is still used, when the skin is cool or the pulse is weak, and when warm stimulating tonics are required. It is most serviceable in the form of infusion, with aromatics and tonics (F. 262, 416, 826). An- gelica root was recommended by Reil, ivvpera- toria root by Hoffmann, and the root of cala- mus aromaticus by Hildenbrand. They are very rarely employed in this country, although they are of service, particularly in the form of infusion, as vehicles for other medicines,, and on account of their warm, diaphoretic* and stimulant effects. They may be employed va- riously combined with each other, or with cam- phor, tonics, &c, and are indicated in the same circumstances as require the use of arnica, viz., in the low nervous and putro-adynamic states. Their infusions are good vehicles for tonics, the chlorates, or alterative salts. I have sometimes prescribed them with chloric acid and chloric ether, or with the chloride of sodi- um and chlorate of potash. 587. e. Cinchona, and other tonics have been praised by Huxham, Lind, Langrish, Grant, Westphal, Sims, Vallisneri, Cassok, For- dyce, and most of the writers on fever during the last century, and by many contemporary authors ; while others have attributed more or less mischief to their use. Whea the various forms of typhoid fevers, their complications, and the very different pathological states in the suc- cessive stages of their course are considered, this contrariety of opinion is easily explained. When the nervous stage has appeared, and when the putro-adynamic state is pronounced, whether early in the disease, as.in the putrid or septic variety, or in the advanced stages of the nervous and exanthematous,, the prepara- tions of cinchona and the sulphate of quinine are the best tonics that can be selected, both for the permanence of their action and for their in- fluence in arresting the disposition to colliqua- 1218 FEVER, TYPHOID—Certain Medicines in tion that pervades the fluids and soft solids of the frame. In the early states of the disease, and where the propriety of having recourse to tonics is a matter of doubt, the infusion of bark, with the solution of the acetate of ammonia, and spirits of nitric ether, or the decoction of cin- chona, with nitre and hydro-chlorate of ammonia (F. 437, 438), will generally prove serviceable. 588. /. The propriety of having recourse to acids in the states of low fever just alluded to has recently been disputed; and if the effects produced by them on the blood be considered, as shown by the experiments of Friend, Eller, Gianella, Haller, &c, and as stated in the article Blood (y 135, 136), rational doubts of their salutary influence may be entertained ; yet the experience of most writers is in fa- vour of them, particularly in fevers of a low character. Spangenberg, Huxham, Langrish, Wood, Mursinna, Rowley, Boyer, Rademach- ER, SCHLEGEL, HoRN, FoRDYCE, BANG, MlLLAR, Frank, Hufeland, &c., recommend the miner- al acids, especially the hydrochloric, in the cir- cumstances mentioned above. From a careful observation of their effects in many cases, I be- lieve that they will prove beneficial in some cases and injurious in others, according to the period and state of fever, and the mode of pre- scribing them. If they are given before the blood has become materially altered and the vi- tal energy much exhausted, but after requisite vascular or alvine evacuations have been carri- ed sufficiently far, while the skin is still warm- er than natural, and while the pulse is broad, open, and compressible, the mineral acids, with tonic infusions, will generally be seviceable. In this state the infusion or decoction of cin- chona may be given, with hydrochloric acid and chloric ether; or the sulphate of quinine, with infusion of roses and sulphuric acid, or also with sulphuric ether. When the prostration is considerable, this latter may be the more en- ergetic medicine. In more doubtful cases, par- ticularly when the heat of surface is great, the infusion of cinchona or of valerian may be giv- en, with the nitrate of potash, or with the ni- trate of soda, a few drops of nitric acid, and the spirits of nitric ether; and when the skin is -cooler, either of these infusions, or some one ■ of the others already mentioned, may be pre- scribed with equal parts of the mho-hydrochlo- ric acid and the tincture of serpentaria. 589. In the treatment of typhoid fevers, it should never be forgotten that the state of the circulating fluids depends chiefly, if not entire- ly upon that of the organic nervous influence, and that agents which apparently deteriorate the blood may yet be of use by administering to this influence. The carbonic acid gas was supposed by Jansenn, Fortier, and Percival ito act as an energetic tonic, when taken into the digestive canal; and they therefore direct- ed the use of those fluids which contain it most abundantly, and even advised it to be thrown i up the rectum. A similar practice was lately recommended by Dr. Clanny, with the view of supplying the blood with this substance. But M. Chomel has shown the inefficacy of < this practice (y 538). The acids which have ; appeared to me most serviceable in the ear- i ly period of the adynamic, nervous, or pu- i tro-adynamic forms, are the hydrochloric and < the pyroligneous acetic, particularly when giv- I i 1 en in the decoction of bark (F. 388), or in ei- ther of the warm stimulant infusions mention- ed above. When the nervous or putro-ady- namic states are far advanced; when the tem- perature is low, and the skin lurid or discolour- ed, I believe that whatever benefit follows the use of mineral acids depends chiefly upon the salutary efforts of nature, or the substances prescribed at the same time. In the state just mentioned, the more energetic tonics and stim- ulants, in conjunction with camphor, the chlo- rate of potash, opium, wine, &c, are much more deserving of confidence. Besides cincho- na and sulphate of quinine, other tonics, as cas- cardla, calumba, gentian, &c, may be used ; but they are inferior to bark, and ought to be given chiefly in conjunction with substances appro- priate to the peculiarities of the case. The willow bark has been recommended by Otto, Schlegel, White, and Hufeland, but it does not appear to be equal to cinchona. 590. g. The chlorates, &c.—The chloride of potassium (muriate of potash) was first employ- ed, under the name of digestive salt, by Sylvi- us ; and, owing to its febrifuge properties, it afterward obtained the appellation of febrifuge salt of Sylvius. It was given in doses of from one to two or three drachms; and, although its action is stimulant, aperient, diuretic, and antiseptic, it has seldom been used in modern times. It is of service in the low stages of fe- ver, and when there is evident change in the circulating and secreted fluids ; but it is inferi- or to the chlorate of potassa in these states. This latter salt was recommended by Garnett and some other writers, but at no time has it been generally used. I have prescribed the chlorate of potash in several diseases since 1819, and consider it a valuable medicine, es- pecially in the advanced stages of typhoid fe- vers. "When excitement or vascular reaction is about to pass into the nervous stage, and when inflammatory determination has been re- moved, either of these salts, but the latter es- pecially, will be prescribed with benefit. The chlorate may be advantageously conjoined with tonics and camphor ; or it may be given in do- ses of five or seven grains, every two or three hours, in tonic infusions, or in larger quantities at longer intervals. A solution of chlorine or of chloric ether, or of both, may be used in the same states for which the chlorate of potash or the chlorides are here recommended. 591. The chloride of sodium, or common salt, although sometimes used in various forms, but commonly as an aperient and anthelmintic by the older writers, has recently been seldom re- sorted to, excepting in enemata, in the treat- ment of low fevers. Formerly putridity was much insisted upon as a characteristic of cer- tain states of fever; for, owing to the intensi- ty and concurrence of the exciting causes, to the treatment, and to the influences in opera- tion through the course of the disease, these changes of the fluids and soft solids, which, al- though not strictly putrid, yet somewhat resem- ble it, or even approach it, were common oc- currences in the course of the inflammatory as well as of the adynamic varieties. These changes, inasmuch as they consist, in some measure, of an incipient dissolution of the vital cohesion of the tissues and of the healthy con- dition of the fluids, quickly passing, with the FEVER, TYPHOID—Certain Medicines in. 1219 disappearance of life, into manifest decomposi- tion, were not altogether inappropriately term- ed putrid; and, for want of a more suitable name, they may still retain the denomination. With the modern disuse of this term, and from a disbelief of the possibility of putridity taking place in a living body, the operation of medi- cines in preventing or counteracting it was de- nied. Thus an antiseptic property was denied to medicines, although it could not be doubted that many substances had the power both of averting and of remedying the changes usually tremed putrid. This power was imputed to their influence upon the nervous system, particular- ly the cerebro-spinal part of it. I have, how- ever, shown at other places, by experiments performed by myself and others, that numerous substances are quickly conveyed into the cir- culation, where they directly change the state of the circulating fluids and secretions, and af- fect the organic or ganglial nervous influence. 592. Conformably with this view, the older opinion as to the operation of antiseptics on the living as well as on the dead body—that certain substances prevent or counteract the changes usually denominated putrid or septic—seems well founded. There can be no doubt that the circulating fluids are contaminated or altered in the course of fever, owing to the superabun- dance of certain constituents, and the loss of others necessary to the continuance of health. The impeded functions of the lungs, the skin, liver, and kidneys, in the early stage of the dis- ease, will occasion the former of these chan- ges, and the stop put to the functions of diges- tion and assimilation—to the sources of supply —will produce the latter. That the chloride of sodium is necessary to the healthy state of the blood cannot be doubted ; it therefore fol- lows that the privation of it, for a number of days, during the treatment of fevers, will ma- terially favour the morbid condition which the fluids assume in the advanced stages. But as other substances, as the chlorate of potash, hy- drochlorate of ammonia, nitrate of potash, and nitrate of soda, act on the blood and on the economy in a similar manner to the chloride of sodium, although not so beneficially, univer- sally, and permanently as this last, which has been so bountifully supplied by nature, we are enabled to account for the benefit derived from the use of them in the advanced stages of fe- ver by writers in the sixteenth and seventeenth centuries. It seems very probable that the common salt taken so abundantly with our food, after having produced the effects arising from its neutral state, is decomposed by the nervous or vital influence, or by the electrici- ties circulating through the frame ; and that each of its constituents performs ulterior offices in the economy that are necessary to the con- tinuance of health, and enters into new combi- nations, produced by the actions of the respect- ive organs in the circulating and secreted fluids. 593. If this view be just, the insufficient supply, or the privation of this salt in the early stages, while the discharge of it continues by the excretions, in either its neutral or its de- composed states, will cause a deficiency of it in the blood in the advanced periods of fever, and will give rise to farther changes both in the circulating and in the secreted fluids. In conformity with this opinion, a modification of the medical and regimenal treatment usually recommended in typhoid fevers should be adopted. It is not improbable that the evils resulting from a total privation of a substance so necessary to the healthy discharge of the functions as the chloride of sodium is, would have been more generally manifest in these diseases if other substances, acting somewhat similarly upon the blood and on the system, had not been commonly employed in the treat- ment of them. I have been led, by the anti- septic properties of certain medicines, to have recourse, in the latter stages of low fevers, to the most energetic of them, particularly the nitrate of potash, the chlorate of potash, the hydrochlorate of ammonia, camphor, and the terebinthinates, cinchona, &c., in various com- binations, either with each other or with differ- ent stimulants and tonics, with the view of exciting the nervous influence, of supporting the powers of life, and of counteracting the changes frequently terminating in a dissolution of the vital crasis and cohesion of the fluids and soft solids. But in fevers which are char- acterized by excessive action at the commence- ment of excitement, and by extreme exhaus- tion, loss of irritability, and depravation of the fluids in the latter stages, a too early recourse to some of these medicines may increase the morbid action, and aggravate local determina- tions ; while a too cautious reserve of them, either as to quantity or as to the period of fe- ver, may allow the diseased changes to pro- ceed without interruption to a fatal issue. It is, therefore, imperatively required of us that we should determine, by attentive observation, both the exact period in which medicines of this description should be commenced with, and the particular substances that should be first employed. As respects the kinds of fever just alluded to, as well as those forms which are either nervous or more uniformly putro- adynamic at earlier stages, we are at no loss for means which are both refrigerant and anti- septic, and which may be employed from the commencement, either when excitement is most excessive, or when it is entirely absent, if due care be taken in the mode of prescribing them. By this early attention, particularly in putro-adynamic and inflammatory putrid fevers, to those means which may best preserve the fluids from the changes they are apt to under- go, especially when these fevers are left to themselves or injudiciously treated, the advan- ced stages are rendered much more mild, and even manageable. The more refrigerant of the substances, formerly termed antiseptics, as nitrate of potash, nitrate of soda, hydrochlorate of ammonia, &c, when duly administered in the early course of fever, and combined with, or followed by those which are more stimulant and tonic, as camphor, cinchona, chlorate of potash, arnica, &e, as exhaustion and signs of putro-adynamia appear, will generally pre- vent the more dangerous changes in the fluids from taking place. The hydrochlorate of ammo- nia is now seldom used internally, although Hoffmann, Jacob, Barchusen, Loesecke, Tis- sot, Werlhof, Monro, Hirschel, Hillary, M'Causland, Gmelin, and others have recom- mended it highly in putro-adynamic fevers. I , have frequently employed it, and Dr. Conwell I has found it of great service in the fevers of 1220 FEVER, TYPHOID—Certain Medicines in. India. Schmidt prefers it in such cases as are attended by diarrhcea. 594. About the time when M. Labarraque discovered the chlorinated soda and lime, cases of fever of a putro-adynamic or malignant form were frequently occurring in an institution to which I am consulting physician. I had made trial of various methods of treatment, but found camphor, in large doses, variously combined, and aided by other means according to the pe- culiarities of the case, the most successful of any. Shortly afterward, M. Labarraque's pro- cess for preparing these chlorides was publish- ed at Paris, and as early as 1825 I procured them from Mr. Morson, for the use of this and another institution to which I was physician. I employed them internally in enemata, and externally, and as disinfectants; and the re- sults were such as have induced me to have recourse to them ever since in the various cir- cumstances and diseases in which I have rec- ommended them in this work. The chlorinated soda is a valuable medicine in all the typhoid forms of fever, when judiciously prescribed. It may be given early in the putro-adynamic variety, when excitement is imperfect or low, and the skin discoloured, or petechiae are ap- pearing, and continued throughout the disease. But when vascular reaction is considerable, or local determination prominent, particularly in the nervous and exanthematic varieties, this substance should be withheld until these states are subdued, or about to lapse into the nervous stage. At first, it ought to be prescribed in small doses, so as not to offend the stomach : in from ten to fifteen drops of the solution, as prepared by Labarraque, every three or four hours in camphor julep, or in an aromatic water. As the disease passes into a state of exhaustion or of manifest putro-adynamia, or when there are a lurid skin, low, muttering de- lirium, stupor, meteorismus, black sordes on the tongue, teeth, &c., the supine posture, un- conscious, offensive evacuations, petechiae, blotches, a disposition to gangrene in parts pressed upon, coma, &c, it should be given in larger doses, or more frequently, and in tonic infusions or decoctions, or with camphor, ser- pentaria, or other stimulants and tonics. I have seen it productive of great benefit in such cases, but it should be commenced before these symptoms appear, and be persisted in, as its good effeets are seldom manifest in less than three or four days, or more ; and it should not supplant the use of wine, opium, suitable nour- ishment, and other means which the stage of the disease and peculiarities of the case may sug- gest. It should also be frequently administered in enemata ; and the surface of the body ought to be often sponged with a stronger solution of it in warm water, with the addition of camphor. M. Chomel has lately given the chlorinated soda an extensive trial; and he states that it has proved more successful in low fevers than any other means, when perseveringly employ- ed. Dr. Graves has also recently employed it, and has found it extremely serviceable. It acts, first, on the tissues with which it is brought in contact as a gentle stimulant and antiseptic, and is most probably partially decomposed in the digestive organs, and reduced to the state of common salt. In this state it is carried into the circulation, where it supplies the waste of this substance that has taken place in the early stage of the disease. 595. The chlorinated lime, in doses of one or two grains, may be also employed with great advantage. When exhibited in solution, it will be preferable to commence with half a grain every hour, or with a grain every two hours, gradually increasing the quantity as the stom- ach may tolerate it. It is best adapted to the more extreme cases of putro-adynamia, and especially to those attended by urgent diarrhcea and meteorismus. In these it may be conjoin- ed with camphor and other stimulants. It was employed by Dr. Reid, of Dublin, in low fevers and in dysentery, a few months after the period of my having first had recourse to the chlori- nated soda. It may be prescribed in the same circumstances and combinations as the latter, but is not so generally appropriate, nor does it admit of so early, or of so prolonged an exhi- bition. * 596. h. Alkalies and alkaline carbonates have been employed in various states of typhoid fe- ver, and frequently with service. The sesqui- carbonate and other preparations of ammonia have been very generally resorted to when diffusible stimuli have been required. In the early sta- ges of these fevers, the sesqui-carbonate may be used with advantage to make a neutral saline mixture with the pyroligneous acid, and either the alkali or the acid may be given in excess, or the mixture may be taken while ef- fervescing. The preparations of ammonia are most useful in the nervous and exanthematic varieties of typhoid fever, and, in conjunction with camphor, or with tonic infusions, in the nervous stage. In the putro-adynamic state they have seldom appeared to me to have any good effect, unless combined with these or other tonics. 597. The sesqui-carbonate of soda and bicarbo- nate of potash are seldom used unless to form neutral citrates or tartrates, and to obtain the fixed air given out during the combination. The advantages of this latter are, however, by no means considerable; but the salts them- selves are of service, by supplying, in some respects, the place of that commonly employed. The carbonate of soda has been occasionally used, and is recommended by Dr. Stevens as an ingredient in his saline powders. In the more adynamic states of typhoid fevers, or in the intestinal complications, the carbonate of soda should be given in a tonic infusion or de- coction, with camphor, and with opium, or ex- tract of poppy, or compound tincture of cam- * Dr. Reid mentions an important fact illustrating the cause of putro-adynamic fevers, a cause which exists to a greater extent than is supposed, especially in large cities, although in a much less degree than in the instance about to be adduced. At Valladolid, during the wair in Spain, the palace of the "Holy Inquisition" was appointed for tha barracks of a British regiment. Under the colonnade was a well, from which water could be drawn into the upper- most stories. This water had a sweetish decayed taste; but, for the want of better, the soldiers used it both for drinking and cooking. No other regiment in the garrison was so unhealthy; and the prevailing disease was putrid fever, of which there was not the slightest symptom in any of the other regiments. At last the reason was discovered : skeletons were found in the well, and several were observ- ed with pieces of the flesh adhering to the bones. If the chlorides of soda or of lime had been then known, or if that which had been long previously recommended been employ- ed, the mortality from this fever, and from putro-adynamic dysentery, would not have been so great as it proved du- ring the Peninsular campaigns. FEVER, TYPHOID—Certain Medicines in. 1221 phor, to prevent it from relaxing the digestive mucous surface, and from increasing the diar- rhoea. Unless it be thus combined, or conjoined with the chloric salts which Dr. Stevens di- rects, it may not only aggravate the affection of the bowels, but also favour relapses, or cause the disease to pass into the dysenteric compli- cation. An acetate of soda, formed by pyrolig- neous acid, with an excess either of the acid, or of the alkali, according to the state of dis- ease, and taken while effervescing, or after- ward, appears to me, from the few cases in which I have had an opportunity of using it, to deserve a more extensive trial. 598. The salts employed by Dr. Stevens, viz., the chloride of sodium, the carbonate of soda, and the chlorate of potash, cannot be supposed to act, even upon the digestive organs, in the states in which they are prescribed, without undergoing some change from their mutual action, and from the fluids with which they mix. Indeed, the results may be assumed to be chlorates of soda and of potash, and car- bonate of soda, taking the proportions of the individual salts into consideration. When these salts are taken into the stomach during the middle and latter stages of typhoid fevers, the passage of at least a portion of them into the circulation may be expected, and the loss of the saline ingredients of the blood in the ear- ly stages, argued for above (y 592), will be sup- plied. Upon this principle, and for the reasons there stated, this method deserves a more ex- tensive trial than it has hitherto obtained ; and when the nature of the salts, and the modes of their operation are considered, it does not seem to differ materially from that by means of the chloride of soda, first adopted by myself. There are certain points upon which Dr. Ste- vens very strongly insists, and which are partly contradicted and partly confirmed by former observers : these are, 1st. The superabundance of acid in the excretions ; 2d. The influence of all acids in rendering the blood dark and gru- mous ; and, 3d. The mischief produced by them in the latter stages of fevers. Now, without disputing the accuracy of the first statement, although a confirmation of it is required, I will admit the truth of the second; for it agrees with my own experiments, and with those per- formed by writers early in the last century, to whom I have referred in the article Blood (y 135). That acids will be injurious in the latter stages of fever, seems a rational infer- ence from these experiments, in connexion with the dark and morbid state of the blood at that time ; and yet numerous writers have recommended them, and adduced proofs of their good effects even in the most malig- nant states of remittent, continued, and exan- thematous fevers. The muriatic or hydro- chloric, citric, and pyroligneous acids have been severally employed in these states, and found of service ; but they have also frequently failed. That the blood is black and dissolved in scurvy cannot be doubted, yet the advanta- ges derived from citric acid have been great, unless some remarkable delusions as to the causes and treatment of this disease have ex- isted ;* and such actually appears, in some * From several opportunities of observation. lam of opin- ion that scurvy has been often confounded with putro-ady- namic fever; that both diseases formerly proceeded from measure, to have been the case. The truth, however, seems to be that, while the patholo- gists have lately been occupied exclusively with the living solids, Dr. Stevens has con- cerned himself only with the blood, and kept too much out of view the influence of life, es- pecially as manifested in the organic nervous system, upon both the circulating and secreted fluids. 599. As far as my own observations enable me to form an opinion as to the respective mer- its of these acids, and of the alkaline carbonates and salts, I conclude, 1st. That the acids may be of service early in fever, while vascular ex- citement is considerable, although vital power may be weak; that they seldom will be injuri- ous in this period, as long as the skin continues warmer than natural and the blood preserves its colour ; and that but little confidence should be placed in them when the surface is at, or below the natural temperature, or materially discoloured, unless they be conjoined with sub- stances calculated to excite the powers of life. 2d. That the carbonates of soda and potash, the solution of chlorine and the chlorides, are pref- erable in the middle and latter stages, more es- pecially when the blood appears morbid, the skin discoloured, and the excretions offensive ; but that the sub-carbonates should not be trust- ed to in the last stages of typhoid fevers, unless conjoined with substances calculated to support the vital energies; and that, at this period, chlorine, the chlorates, and chlorides should be preferred, as being more tonic, stimulant, and antiseptic than the carbonates. 3d. That the sulphate of soda, the phosphate of soda, and. the sulphate of magnesia are severally of service in the stage of excitement, when they may be giv- en, at first so as to act gently on the bowels, and afterward in small doses, as refrigerants or alteratives; and that the chlorate of potash, the citrates, and acetates may likewise be employed with the latter intentions. And, 4th. That cir- cumstances may occur, in which it will be ad- vantageous to exhibit the neutral salts with ei- the same causes, and often occurred simultaneously in the same camp, army, fleet, or ship; that the causes were chiefly putrid water, mouldy and adulterated bread, dis- eased and unwholesome flesh, vegetable and animal exha- lations, insufficient nourishment, and the depressing pas- sions ; and that the protracted use of salted provisions of a good quality was but little concerned in producing either ot these diseases. During the seventeenth and eighteenth centuries, trading vessels were provisioned as cheaply and as sparingly as possible, and fleets and armies were provi- ded by contractors, who enriched themselves and those who passed their supplies at the expense of the lives of thou- sands. Bread which was actually nauseous ; the flesh of animals dead of epizooties ; provisions which had been ei- ther salted for years, or neaTly half putrid ; numbers sleeping in a small space and in imperfectly renewed air ; the con- stant evaporation from the too frequently washed decks ; water kept in wooden casks until it became blackish, inky, stinking, and nauseously putrid, were causes of fever often in protracted and simultaneous operation. I have never been in a ship in any other capacity than as a passenger; but some of my voyages have been long, and have afforded me occasions of witnessing, even at the commencement of the nineteenth century, the existence of some of these causes. For many years matters have been altered, espe- cially in the navy. The mutiny at the Nore ; the advance of knowledge ; the stricter attention to the supply, prepara- tion, and quality of the provisions ; the preservation of wa- ter in iron tanks, and some other subordinate circumstan- ces, have done more to banish putrid fevers, dysentery, and scurvy from our fleets than the use of citric acid or any oth- er antiscorbutic or antiseptic ; and I have no doubt that the prevention of these causes, and the general adoption of the chlorides, will be found the most certain means of prevent- ing and of curing these diseases. 1223 FEVER, TYPHOID—Certain Medicines in. ther an acid or an alkali, as the chloride of so- dium, with a vegetable acid, as prescribed by Morgan ; or with soda, as advised by Stevens ; or to prescribe saline substances with an ex- cess of either of their constituents, as the chlo- rates with an excess of acid or of alkali. 600. i. Opium, &c.—Much difference of opin- ion has existed as to the propriety of giving opium in typhoid fevers. But when we find Sydenham, Polidori, Rolfinck, Schlegel, Van Hoven, Home, Horn, Marcus, Latham, Stokes, Graves, &c, favourable to the practice, the grounds of dissent from it ought to be careful- ly examined. There are circumstances and states of fever which forbid its use, but there are others which as imperatively require it; and I believe that the objectors err grievously in not discriminating between them, and in not studying either the conditions which contra-in- dicate it, or the modes of exhibiting it in the cases that would be benefited by it. Syden- ham considered that it prevented coma or stu- por, when given after vascular and alvine evac- uations had been judiciously employed. Odhe- lius, Gilchrist, Home, and Graves combined it with antimonials, and the propriety of the practice cannot be doubted, in the circumstan- ces in which they employed it. In the present day, the indications for the exhibition' of opi- ates have been so ably stated by two accom- plished physicians — Dr. Latham and Dr. W. Stokes—that whatever I may advance as to this subject must, in great measure, be an echo of their observations. When the disorder of the sensorium outruns the other symptoms; when by venaesection or topical bleeding, or by alvine evacuations and refrigerants, the gener- al and local symptoms are relieved, but the de- lirium still continues ; when to this state are added tremours, subsultus tendinum, and unre- strained evacuations ; when there has been, at first, high vascular excitement, and large evac- uations have been required to guard the brain or other organs from mischief, and wild delir- ium has followed ; if the patient has previous- ly been in a delicate or nervous state ; if he has been addicted to an excessive use of spir- ituous or vinous liquors, particularly the for- mer ; if the habits of the patient and his occu- pations have been such as to inordinately ex- cite and exhaust the sensorium ; or if the anx- ieties, the toils, or the debaucheries of life have previously injured the health, and more espe- cially the state of nervous energy; in these several circumstances should opiates be resort- ed to in the advanced progress of typhoid fe- vers, and of synochoid fever that has passed into the nervous or typhoid state. On most of these, Dr. Latham has insisted with great pre- cision and force, and I entirely subscribe to the value of his remarks. Dr. Stokes remarks that three circumstances call for the use of opi- um in fever: 1st. Where there is persistent watchfulness; 2d. Where an inflammatory con- dition of the brain has existed and been sub- dued, but delirium or other nervous symptoms still remain ; 3d. Where an excited state of the sensorium exists without heat of scalp, or remarkable throbbing of the arteries of the head; and to these I may add a fourth, Where there are much relaxation of the bowels, unrestrain- ed evacuations, tremours, watchfulness, or de- lirium, or subsultus tendinum. 601. The mode of exhibiting opiates is some- times of great importance. In many cases, one or two grains of solid opium may be given, ei- ther alone, or with camphor and nitrate of pot- ash. The combination with camphor is to be preferred when there is much adynamia, and no inflammatory determination to the brain. When the bowels are very remarkably disor- dered, ipecacuanha may be added to these. The acetate of morphia is often superior to pure opi- um, when given in doses of from a quarter to half a grain, with camphor, or with aromatic spirits, or warm spices, as Cayenne, &e, par- ticularly in cases of extreme prostration. The hydrochlorate of morphia may be preferred, if the chlorates are also prescribed. Opiates are sometimes of service when exhibited in small mucilaginous enemata. Hildenbrand, who is averse from the use of opium in the exanthe- matic typhus, unless under circumstances man- ifestly indicating it, very justly remarks that, when it is determined upon, it should be given in a full or large dose, once or twice repeated after a proper interval, rather than in small and often-repeated doses. 602. Other narcotics may be prescribed in cer- tain states of typhoid fever, but they are not so deserving of confidence as opiates. The ex- tracts of poppy and hyoscyamus are occasionally useful, particularly when opium disagrees ; but even in such cases, the acetate of morphia, pre- scribed as just directed, will be of service. Brera praises belladonna in the states of fever indicating the propriety of having recourse to opium. This narcotic is sometimes useful in the delirium attendant on erysipelas of the scalp. Mr. Blackett (Lond. Med. Repos., vol. xix.) recommends it in similar circumstances. It seems deserving of trial in the states of ner- vous fever mentioned above, and in the ner- vous stage of exanthematic typhus. 603. k. The use of wine and of some other stim- ulants requires much discrimination. It has been supposed by some writers that wine is contra-indicated where there are delirium; a dry, black, or red tongue ; red or suffused eyes; or much heat of surface. This is partly true; but one, or even more of these symptoms may be present, and yet wine will prove of great benefit. Indeed, wine may be exhibited in the same circumstances as require the use of opi- um. When the delirium is of the kind above stated (y 600), and is accompanied with the same phenomena, &c. ; when the state of the tongue is the result of extreme adynamia, in- flammatory determination having been subdu- ed ; when the suffusion or redness of the eyes is the result of want of sleep, and is attended by a cool scalp ; and when the heat of skin ex- ists chiefly on the trunk, and is attended by in- dications of putro-adynamia, then wine will be given with benefit, and it is even indicated. This subject has been very ably canvassed by some contemporary writers, particularly by Drs. Wilson, Philip, Alison, Graves, Stokes, and Tweedie, whose experience gives weight to their opinions, and they very nearly concur with me in the propriety of exhibiting wine with due precaution even in these circumstances, as well as in others which are less doubtful. Gilchrist, Heisham, Halls, Wensel, Harles, MATTHiEi, Hufeland, Horn, and others, even notice the influence of wine in reducing the heat of skin, FEVER, TYPHOID- in fevers tending to putro-adynamia, and my own experience confirms the observation. 604. The indications for the exhibition of wine in the typhoid states of fever may be re- duced to the following : (a) When the patient has been proceeding favourably, and the pulse suddenly becomes weak, very soft, or irregu- lar ; the skin cool or damp ; the countenance collapsed; and the strength prostrated ; (b) When the patient complains of a feeling of ex- haustion, and expresses his wish for wine or support; (c) When vital depression occurs un- expectedly or suddenly, or without any evident cause ; (d) When the depression is owing to injudicious depletions, or excessive evacua- tions, or to the depletions or other means re- quired to subdue inflammatory determinations at an advanced stage, or to protracted or ex- cessive diarrhoea, or to haemorrhage from the bowels, or from any other part; (e) When, with these symptoms, the abdomen becomes tym- panitic, and the exhaustion increases; (/) When the delirium is low, muttering, and constant, and attended by tremours, or subsultus tendi- num ; the surface, and partieulfrly the scalp, being cool, the pulse soft, weak, or small, and the posture supine ; (g) When petechiae or vi- bices of a dark hue, and other signs of putro- adynamia appear, the scalp being cool and the action of the carotids not materially excited ; (h) If early convalescence be slow, unattended by local affections of an inflammatory tenden- cy, and owing chiefly to debility ; (i) If, with one or more of the foregoing indications, or with a soft pulse, moist tongue, or cool skin, in the latter stages, it be ascertained that the pa- tient has been addicted to spirituous liquors, or to wine in excess ; (k) and if the character of the epidemic be of a low kind, and if the early excitement be attended by weak vital resist- ance, and soon pass into exhaustion, then the propriety of having recourse to wine or other active stimulants, with requisite precautions, cannot he disputed. 605. The kind of wine, its quality, and its quantity, are deserving of particular attention Old sherry, Madeira, and white hermitage, of the best quality, should be preferred. The red and acid wines are most apt to disagree, yet port and red hermitage are useful in some ca- ses, particularly when diluted and conjoined with aromatic spices in the form of negus. Na- vier recommends Champagne ; but it is suita- ble only to the stupor or coma attendant upon an extreme state of adynamia. The quantity of wine given in the twenty-four hours should depend upon several circumstances; but it may vary from four or five ounces to sixteen or twenty. Dr. Bateman thinks that it should not exceed a pint; very much larger quantities have, however, been given with benefit; but these are only the exceptions from the gener- al rule. Regard ought to be had to the age and previous habits of the patient, as well as to the state of the disease. Young persons are readily excited, and should take only the smaller quantities. Older patients, and those especially who have been habituated to much wine or to spirituous liquors, often require the full amount just named. The use of it ought always to be commenced in small quantities, and increased as the indications may guide the practitioner. In all cases, it should either be ■Certain Medicines in. 1223 diluted or given in the patient's food, and the effects carefully watched. Dr. Tweedie justly observes that, if the patient relishes the wine, if he is tranquillized by it, and if there is a grad- ual and steady improvement in the symptoms, without any marked excitement after it has been taken, benefit will result from it. On the other hand, if the pulse or heat of the skin are much or quickly raised by it, if the face be- comes flushed, and the patient restless or in- coherent, wine is either improper or the quan- tity has been too great. If, after having been stimulated, he soon lapses into the previous state of exhaustion, or seems weaker from each successive dose, no advantage will be obtained from it. When wine has produced the desired effects, it should be gradually withdrawn. 606. Other fermented liquors, particularly when bottled, and even brandy, have been used in the circumstances indicating the use of wine. I have employed bottled stout with ben- efit ; it is an excellent vehicle for the carbonate of soda or of potash, or for small doses of the hydrochlorates, or for both conjointly, and is most appropriate to the advanced stage of pu- tro-adynamic fever. Spruce beer, ginger beer, and Seltzer water may severally be employed, and in a similar manner. Brandy ought to be much diluted, and is best suited to those who have been habituated to spirituous liquors. In cases attended by a protracted or colliquative diarrhoea and extreme prostration, the brandy should be burned, and given in some thin sago or arrow-root. 607. Yeast has been frequently recommended in typhoid fevers. Dr. Stoker considers that it may be given in all the stages in which it can be retained by the stomach, even when the existence of inflammatory complications pre- vents the use of other stimulants; and that it is generally easily taken alone or with any oth- er medicine, or in any vehicle that may be deemed advisable. In the worst forms of ty- phus, when it is most needed, he states that it is rarely rejected, but, on the contrary, is much relished; and that it is moderately laxative, often superseding the use of purgatives. If it prove not sufficiently aperient, he gives a lit- tle tincture of jalap in it; and if the bowels are too much relaxed, a few drops of tincture of opium are added to each dose. It appears to Dr. Stoker to correct the morbid contents of the alimentary canal, and the consequent symp- toms of putrescence, petechiae and black tongue being more effectually removed by it than by any other means. He has, therefore, substitu- ted it for bark and wine, when they could not be employed on account of inflammatory symp- toms, and has conjoined it with them when there was no such counter-indication. He pre- scribes the yeast in doses of two table-spoon- fuls every third hour, with an equal quantity of camphor mixture. If administered in enemata, three times the above dose may be employed. Dr. Stoker, whose experience of this treat- ment has been long and most extensive, ob- serves that instead of increasing the tendency to tympanitic distention by promoting ferment- ation, as may be objected, it actually prevents the accession of this symptom ; and that in the most obstinate instances of typhoid tympany he has found enemata of yeast and asafcetida the most efficacious remedies. 1224 FEVER, TYPHOID—Certain Medicines in 608. Other stimulants require little attention. Musk has been recommended by the Franks, Gebel, Gmelin, Marcus, Horn, Stoker, and others in cases of true adynamia—of extreme prostration, with much affection of the senso- rium. It may be prescribed in the same cir- cumstances as admit of the use of wine : Tho- mann, however, found it quite inefficacious. It should be given in large doses to be of any service—from ten to fifteen grains, with cam- phor or ammonia, or other medicines which the peculiarities of the case will suggest. Phos- phorus and phosphoric acid have likewise been employed; they do not appear to possess any claims to particular notice, but may be inju- rious if too liberally or inappropriately admin- istered. I have seen benefit derived from the infusion of green tea when the stupor or coma has been great; and I believe that strong cof- fee has sometimes proved useful in similar states : it has been recommended by Zambelli and Grindel. The warm spices, especially capsicum, are often of service, and may be given in considerable doses in the latter stages of ty- phoid fevers, but chiefly as adjuvants or corri- gents of other remedies. The spirits of turpen- tine are frequently productive of benefit when prescribed in small doses, with aromatics or spices; but a large dose may be attended by very serious consequences when exhaustion is extreme. It is an excellent medicine in ene- mata, with castor oil, chloride of sodium, or other purgatives when the bowels require to be opened ; and with asafcetida, or extract of rue when there is much tympanitic distention. Substances of a similar kind, or the usual car- minatives, have been directed in enemata by Thomann and Hufeland, in order to remove this symptom; but the injection just recom- mended is the most certain in its effects. The means noticed above (y 158) may also be re- sorted to. When there is haemorrhage from the bowels, these are generally efficacious ; if they fail, a solution of the acetate of lead in pyroligneous acid, with the addition of crea- sote, may be thrown up in any vehicle which the peculiarities of the case may require. 609. Many practitioners are averse from giving stimulants or tonics in typhoid fevers, from a fear of thereby aggravating or inducing inflammatory determinations. But even where the nervous inflammations noticed above ($495) may be presumed to exist, and particularly in an advanced period of these complications, a judicious use of stimulants is actually neces- sary. It is a well known fact, and well ex- pressed by Dr. W. Stoker, that, at a certain period of inflammatory affections, stimulants become antiphlogistics; and this is more es- pecially the case in respect of these affections when they occur in the course of fevers ; the nervous energy is then depressed, irritability is most remarkably impaired, the fluids changed, and the whole constitution incapable of mani- festing the phenomena, or of developing the lesions, constituting true or sthenic inflamma- tion and its consequences. A spurious or as- thenic state of action only, quickly passing into disorganization, can possibly take place in these circumstances ; and it can be remedied solely by stimulating and antiseptic means. These facts are frequently placed before our senses, •and demonstrated by the treatment found most beneficial, as well by that most injurious in malignant sore throat. 610. /. Various external means have been sug- gested for typhoid fevers ; some of the most serviceable of them have already been noticed. The cold affusion over the general surface is very rarely admissible in this class of fevers ; but, applied to the head only, it is often of manifest service when the determination to the encephalon in the early stage of excitement is great, or when the delirium is high or mania- cal, or attended by increased heat of the scalp and excited action of the carotids. In these cases it lowers morbid action remarkably, and procures sleep. Tepid bathing and sponging are favourably noticed by Brocklesbury, Wolff, Jackson, Halle, Brandis, and others. Tepid or warm sponging with a solution of the chlo- rides, or of the nitro-hydro-chloric acids, or of camphor in pyroligneous acid, are deserving of general adoption. Tepid or warm aromatic baths, or sponging the surface with infusions or decoctions of aromatic plants, have been em- ployed by MaeBks. Horn, Harles, and Dlpin. Kerksig adviMfiwurm aromatic embrocations to be placed over the abdomen when there is diar- rhcea or meteorismus. The use of blisters has been sufficiently noticed; they may be applied over or near the affected organ when the af- fection consists chiefly of congestion or im- paired action. In other circumstances they may be used as derivatives. This remark is applicable to the use of sinapisms, and to the warm turpentine embrocation. Callisen rec- ommended boiling water to be used as a blister and derivative ; and the idea has been adopted by some recent writers. One of the most ben- eficial external means that can be employed is a liniment, consisting of the compound cam- phor liniment, with soap and Cayenne; this may be rubbed gently but assiduously over the hypochondria, or insides of the thighs, twice or thrice daily. I have occasionally resorted to this treatment for upward of twenty years, and often with great benefit. Several of the liniments prescribed in the Appendix may be used; but the Cayenne should be added, par- ticularly when sensibility and consciousness are impaired. Dry cupping may also be tried as a derivative during the early or middle sta- ges of the disease. In the putro-adynamic state it is seldom admissible. 611. iv. As to the Prophylactic Measures that may be resorted to in typhoid fevers, it is un- necessary to add anything to what is stated above (y 117, et seq.), and in the article Infec- tion ; the means there recommended are quite applicable to these diseases. 612. v. The Diet and Regimen in typhoid fe- vers are particularly deserving of attention; both ought to be suited to the stage and form of the disease.—a. In the early period of ex- citement the air should be pure, dry, cool, and without any current; the apartment should be large and open, the bed without curtains, and the air renewed, without exposing the patient to any chill. Barley water, fresh whey, rice gruel, or common gruel, with a little salt when the excitement is low, or when thirst is not much complained of, may be employed as the usual beverage. The temperature of the drink and of other ingesta should be tepid, or some- i what above it. If bronchial or catarrhal symp- FEVER, TYPHOID—Certain Medicines in. 1225 toms are present, warm, mucilaginous, and mild diaphoretic drinks should be allowed. It is improper in this stage to attempt to excite perspiration by warm coverings. If stupor is present in this stage, the external senses may be stimulated, and neither light nor noise need be excluded. 613. 6. In the nervous stage the air of the apartment should not be too cool, and the bed- clothes ought to be warmer. A uniform tem- perature, and the purification of the atmo- sphere, must be always attended to. A cold, moist air, and currents of air, during this stage, induce diarrhoea, bronchial or pulmonary con- gestions, or other dangerous complications ; while a too warm, close, and impure air, par- ticularly when breathed by a number of per- sons, favours the development of putro-ady- namic changes. The greatest cleanliness is requisite. Neglect of this produces gangre- nous sores and ulcers, particularly where pres- sure is made or slight bruises have been in- flicted. The tongue should be scraped, and the teeth and mouth washed with salt and wa- ter, or gargled with them or with the chlorides, if the patient can do so. The hair may be cut off in the early stage ; but the removal of it in this may be injurious, if the adynamia is ex- treme, and the scalp cool at the time. 614. In the nervous stage, bland, very di- gestible, and fluid nourishment may be allow- ed. The drinks should be mucilaginous, and gently warm. Whatever food or drink is used, whether gruel, thin arrow-root, &c, or weak animal soups, broths, beef tea, &e, should con- tain the usual quantity of salt, for the reasons stated above (y 593). If the treatment by the chlorides, &c., is adopted, this becomes a mat- ter of less importance. Fruit tends to produce diarrhcea, and is seldom admissible. Wine, as advised above, is generally required, particu- larly when this stage passes into extreme pros- tration ; and may be given in the nourishment adopted, or in soda water, Seltzer water, &c, diluted with warm water, or with tepid fresh whey. If brandy be used, it may be given in the same vehicles, or in weak black tea, in a state of much dilution. In the true typhus, stimulating the external senses is more neces- sary in this stage than previously; and it is often beneficial, as Hildenbrand and Naumann advise, to rouse the patient's moral sentiments and affections, and to disperse his fugitive and chaotic ideas, by recalling former associations and objects of affection or of ambition. In ex- treme cases, however, the physical powers should be excited at the same time as the mor- al, otherwise the latter will be appealed to in vain. In a case of putro-adynamic fever in which I took great interest, these united means proved successful in rallying the energies of life, under peculiarly unfavourable circumstan- ces. During an expected crisis, a greater warmth of the bed-clothes is proper, and warm whey or other appropriate fluids should be giv- en to encourage salutary evacuations (y 167). 615. c. During the abatement of the disease, the importance of diet and regimen increases, as treatment by medicine is now gradually abandoned. Nourishing food of easy digestion, taken in small quantities, pure air, and wine in some cases, are generally required ; but these should be strictly prescribed as to kind, quan- 154 tity, and frequency, according to the peculiari- ties of the case. As convalescence becomes es- tablished, the animal broths and soups may be succeeded by a little solid animal food of the lightest kind. The dangers to be apprehended during recovery have been fully stated above (y 168), their causes assigned, and the means of preventing them pointed out (v f69). Little farther is, therefore, now required. But it will be most useful to recollect that the manage- ment of convalescence should have some ref- erence to the particular form and complication of the disease. In the exanthematic typhus, the danger of consecutive disorder is the least, particularly if it have run its course regularly, and terminated by crisis. After low, nervous, and putro-adynamic fevers, affections of the brain, liver, bowels, lungs, and mesenteric glands are not unusual, particularly when the patient has been prematurely exposed to chan- ges of weather, to irregularities of diet, &e, and when the treatment has been injudicious during early convalescence, or too soon relin- quished. In all the varieties, the risk of these affections is increased by the complications which the fever presented, the organ which was prominently deranged remaining longer weak, or more susceptible than others of being disordered by excitation or by injurious agents. Therefore, in cases where the predominant dis- order has been expressed on the encephalon, particular care should be taken to preserve the sensorial functions from early excitement or irritation, or undue exercise. Where the re- spiratory organs have been much affected, pre- mature exposure to cold, or to changes of tem- perature, &c, ought to be guarded against; and where the digestive organs have manifest- ed the onus of morbid action, the return to a full or stimulating diet should be long delayed, and the most digestible food only ought to be taken, and in moderate quantity. (See farther on this subject, y 167-170 ; and art. Debility, y 36-46.) [It is a disputed point whether typhoid fever is ever arrested or broken up by medication. Dr. Nathan Smith remarks that he never was satisfied that he had succeeded in cutting short the disease in a single instance, and that he had never seen a case terminate within four- teen days from its first attack.* Cases, he says, have often occurred where the distress and sufferings of a patient have been alleviated in less than half that time ; but the morbid ac- tion has not ceased, nor a healthy one of the secreting surfaces been established, and a nat- ural appetite restored, within the time above mentioned. Dr. Miner, on the other hand, tells us that, when called within twenty-four hours after the attack, he never fails in subdu- ing the disease in two or three days at farthest; and that, taking cases together, he succeeds in producing a resolution in one case in eight or ten.t Dr. M.'s treatment in typhoid fever con- sisted chiefly in slow and moderate purging with calomel, for the purpose "of changing ac- tion, and preparing for a subsequent supporting and tonic course." The calomel treatment was continued for a period varying from five to seven days, when the system was generally prepared for the use of stimulants and moder- * [Essay on Typhus, p. 70.] t [Essays on Fevers and other Medical Subjcct.i, p. 105.] 1226 FEVER, TYPHOID—Certain Medicines in. ate tonics. In cases of great prostration, Dr. I M. recommends the use of powerful stimulants, as cantharides, capsicum, alcohol, arsenic, oil of turpentine, phosphorus, &c. ; although he states that ordinary cases only require, after the preparatory process, a light and moderate, though uniform support, with wine, cinchona, and small doses of opium. Dr. M. alludes to the great difference in the severity, violence, and rapidity of the disease in different towns and seasons; being so mild in some as to re- quire scarcely any treatment, and so severe in others as to prove fatal in many instances un- der the most judicious plan. We have former- ly seen many cases of typhoid fever treated after the stimulant plan recommended by Drs. Miner and Tully of Connecticut, especially with very large doses of brandy and opium, and we are yet to be convinced that it is not a practice attended with peculiar hazard, if not often leading to fatal consequences. Dr. N. Smith has truly observed that it does not fol- low of course that this disease in all cases re- quires remedies, or that a patient should neces- sarily take medicines because he has the dis- ease. Where typhoid fever goes on regularly in its course, without any symptom denoting danger, it is now generally agreed that the ex- pectant plan is by far the best, and that power- ful means are liable to do great mischief. If bleeding is resorted to, it should be at an early period of the disease, and then not coup-sur- coup, as recommended by Bouillaud ; and leech- es or cups may be used with advantage in local complications, or inflammation of particular organs. Where there is great pain in the head in the commencement, or severe pulmonary engorgement, the loss of from twelve to six- teen ounces of blood will often afford great re- lief, and enable the patient to go through the disease with greater safety; but as a general rule, bleeding will not be required, for it rarely produces any considerable change in the dis- ease, neither rendering the pulse slower, nor perceptibly diminishing the heat of skin. Emet- ics have been recommended in this disease, es- pecially antimonials, by Dr. Jackson, on the contra-stimulant plan ; but their use is consid- ered by others as not unattended with danger. The same remark will apply to the use of ca- thartics. We are to bear in mind that one of the most constant of the pathological conditions is inflammation of the follicles of the small in- testines ; that their mucous coat is in a state of intense hyperaemia, or actual ulceration, and that irritating substances, whether of food or medicine, are calculated to increase the local affection, and thus aggravate the disease. In mild cases, it is better to adopt Dr. Smith's plan of leaving the disease to cure itself, con- fining the patient to farinaceous food and sim- ple diluent drinks, with occasional mild laxa- tives. Where there are nausea, sickness, and oppression at the stomach, this writer recom- mends emetics of ipecacuanha, eupatoreum, or sul- phate of zinc, and cautions against the use of an- timony as a highly dangerous agent. The ty- phus fever has been treated with eminent suc- cess at the Bellevue and other hospitals of this city, by giving ipecacuanha, in one or two grains, every two hours, until the tongue be- came moist, and then allowing wine, porter, ammonia, camphor, in moderate quantities, guarding against local accidents by leech- ing, cupping, blistering, and fomentations, and merely regulating the bowels by enemata, and occasional doses of oil. Dr. E. Hale agrees with Nathan Smith and others in relation to the treatment of typhoid fever, and remarks that it " is very doubtful whether any treatment has any direct tendency to remove the disease; and that active treat- ment in this form of fever never does good, but invariably does harm ; exhausting the patient without removing the disease, and therefore rendering him less able to throw it off by the inherent energies of his own constitution." Dr. H., therefore, condemns all active interfe- rence, and the whole class of antimonials and salines, and medicines designed to equalize the circulation, as calculated only to disturb and irritate the patient; while tonics, he observes, only tend to increase the fever. Where the stomach is disordered, as it often is at the commencement, a gentle emetic may be given to correct it; and if the bowels are costive, or the dejections morbid, mild cathartics are re- quired ; a light, farinaceous, and milk diet, and cooling, soothing drinks. Where there are symptoms of local inflammation, they are to be combated by bleeding, leeches, or blisters, as circumstances require. Above all, the patient is to be kept quiet, avoiding everything that has a tendency to excite, or to call into ener- getic action any function of the body, or any faculty of the mind ; always remembering that, however mild the disease may at present ap- pear, any imprudence may suddenly throw the patient into a state of great danger. The pa- tient may take, as a placebo, a little of the ace- tate of ammonia and spirits of nitre, or opiated tincture of camphor; or some mfld vegetable infusion, especially if there is any tendency to diarrhoea. "The frequent repetition of anti- monials," says Dr. Hale, " or Dover's pow- der, day after day, is enough to drive a well man into a fever; and even spiritus mindere- ri, or mucilage of gum Arabic, if too often re- peated, or too long persevered in, might throw him into a state of nervous irritation, danger- ous to the physician at least, if not to the patient." Dr. Bell recommends cold bathing, or spon- ging the skin with cold water ; cold applica- tions to the epigastrium and head, and the free circulation of cool air in the room of the pa- tient.* Where nausea is present, he would * [Dr. Nathan Smith speaks very highly of the use of cold water externally and internally in the treatment of ty- phus (typhoid) fever, and says that where the patient de- sires cold drinks, they should be allowed ad libitum. Dr. S. was accustomed, in cases where the patient was too weak to be removed from bed and placed in an erect posi- tion, to dash from a pint to a gallon of pure cold water over his head, face, and body, the bed-clothes being turned down, and the patient reclining on a straw bed; as soon as the heat about the head and body began to return, the watft was again applied in a similar manner, and repeated with sufficient frequency as to keep the surface at such a temper- ature as to feel cool to the hand of a healthy person. Dr. S. remarks that it is not very material what the tempera- ture of the water is, if it lie below blood heat, excepting that it be cold enough to produce some shock where there is much stupor or coma, the efTect being chiefly produced by evaporation. Several cases are related by Dr. S. (toe. cit.) where striking benefit resulted from the application of cold water in this disease. The following is one in point: '' J. B., a strong, robust man, aged between thirty and forty, had been sick a fortnight when I first visited him; hii pulse was frequent, his heat great, and his mouth exceed- ingly parched, so much so that he could not sleep bnt for » FEVER, TYPHOID—Certain Medicines in. 1227 give an emetic, for the purpose of producing secretion and excretion ; and, in the advanced stages of the disease, where the secretion of mucus is excessive and almost suffocating, he thinks emetics calculated to afford at least tem- porary relief. Attempts should be made to quicken the action of the depurating organs, and for this purpose calomel should be admin- istered in small doses, to aid the liver and bowels; turpentine, nitre, and hydriodate of potash, to act upon the kidneys; senega and squills, the lungs ; and, where bronchitis is present, calomel and the senega snake-root are particularly useful. Pure fresh air power- fully contributes to free the lungs from their morbid bronchial exudation, quicken the capil- lary circulation, with its accompanying pro- cesses of decarbonization and oxygenation of the blood. Dr. Stokes has derived an indication for the use of stimulants, especially wine, in typhus fever, by auscultating the heart; and believes that where there is diminished impulse, as well as feebleness of the first sound of the heart, these agents may be advantageously employed ; and the results of his observations show that these take place on or about the sixth day. The directions of Dr. Armstrong in relation to per- severance in the use of wine in typhus fever are worthy of attention. If the tongue be- comes dryer, the pulse quicker, the skin hotter, the breathing more humid, or the patient more restless, it does harm; but if the tongue be- comes moister, the pulse slower, the skin cool- er, the breathing slower and deeper, and the patient more tranquil, it does good. We are not to forget the importance of administering, at regular intervals, small quantities of farina- ceous food for the purpose of sustaining the strength, as many patients doubtless succumb for the want of suitable nourishment. We have found wine whey, with well-prepared ar- row-root, an admirable cordial, and nutrient in these cases. We have rarely found opium ne- cessary or useful in the treatment of typhoid fever, when given alone; and as it tends to check the secretions, and to increase the heat of the skin and pain in the head, it must be used with caution. When combined with cal- omel or ipecacuanha, it may do good in some stages of the disease; and especially if diar- rhoea be present, it is often necessary to check the discharges ; and to meet this indication, we generally combine it with ipecacuanha and camphor. We are, however, satisfied that this article has done much injury in the treatment of typhoid fever in New-England, especially when given as a stimulant, and without regard to the circumstances of the case or the true pathology of the disease. Neither is any de- very few minutes at a time without being awakened by a sense of thirst. His feet were very cold. This individual had been badly treated, and his friends had been prevented from changing his linen and bed-clothes by the physician, who had fears that he would take cold. The patient was first shaved, an operation which had not been performed for something like a fortnight; he was then slipped down in the bed, so as to drop his feet into a vessel of warm water and soap, where they were rubbed till they became clean and warm. The bed and body linen were then changed, and he was properly placed in bed. The effusion of cold water was commenced over the head and breast, and re- peated sufficiently often to keep down the heat. The dis- tressing thirst was removed at once ; he became convalescent the next day, and recovered without any farther medical treatmens." (Med. and Surg. Memoirs, p. 93.)] 1 pendance, so far as we have observed, to be placed on mercury, given so as to produce its constitutional effects ; the disease running its course unabated, even after salivation had ta- ken place. Dr. Smith relates many such ca- ses where he had been called in consultation ; the convalescence commencing several weeks after the establishment of salivation, and the patient slowly recovering eight or ten weeks from the time of attack. Mercury is no specific for typhoid fever, and can only be used as a valuable auxiliary to other means. Too much attention cannot be paid to ventilation, clean- liness, and the due regulation of the diet. The treatment of typhus fever is to be regu- lated by the same general principles which have already been laid down as applicable to the management of the typhoid variety. After they are fully formed, both would seem to have a determinate course to run, and therefore, to a certain extent, are not amenable to the re- sources of our art. We are therefore driven to the necessity of endeavouring, by proper measures, to diminish the severity of particu- lar symptoms, and thus contribute not only to the comfort of the patient, but, at the same time, prevent or relieve local complications, which, unchecked, would endanger life. How often do patients under an attack of fever suc- cumb to excessive evacuations, or functional disorders of particular, organs, which, by suita- ble measures, might have been arrested or ren- dered innocuous 1 We are satisfied, moreover, that in the treatment of our continued fevers, as well as other diseases, far too little atten- tion is paid to hygienic means, both in the way of precaution and cure. As typhus fever is now acknowledged, on all hands, to be a con- tagious disease, too much attention cannot be paid to ventilation and cleanliness, for these are the only certain and absolute disinfectants known ; the chlorides being the next best sub- stitute, where these are wanting. But as the former are in all cases practicable, their neg- lect, in every instance, is inexcusable and cul- pable. Wherever petechial typhus has become epidemic and peculiarly fatal, it has been under circumstances where these conditions have been wanting ; as among the crowded inmates of hospitals, infirmaries, and poorhouses, or the dirty lanes and alleys of large cities. From neglecting the removal of the excretions and evacuations of the sick, and the admission of fresh air into the apartment of the patient, we have known repeated instances, in the healthy mountain districts of New-England, where watchers and others visiting the sick have contracted the disease, and they, in their turn, communicated it to others, and so it has been extended over wide districts of country, and, in fact, become a perennial endemic. We have no doubt whatever that, with suitable precau- tions, the disease might eventually be checked, and even extinguished, especially in places where there are no local causes for its exten- sion and perpetuation. As to particular reme- dies in the treatment of typhus fever, sufficient has already been offered. Bleeding is not gen- erally applicable in any stage of the disease, though cups and leeches may be applied to ad- vantage for the relief of local complications. The heat of the surface should always be mod- i erated by cool or tepid sponging, and the chlo- 1228 FEVER, TYPHOID—Bibliography and References. ride of soda may sometimes be employed for | this purpose with great benefit. The efferves- cing draught will often be grateful to the pa- tient, and tend to allay morbid irritability of the stomach. The drinks should be water, or rennet whey, or some simple vegetable infu- sion of a bland or slightly tonic nature. Where there is much prostration, wine and camphor are the best stimulants; to be succeeded by qui- nine, when the fever subsides and the skin be- comes cool; animal food, in small quantities, being also substituted for farinaceous. Where there is insomnia, and the patient is in danger of exhaustion from agitation and nervous rest- lessness, opiates, especially morphine, or the opiated tincture of camphor, will prove of great benefit; but they are hazardous, if there is much confusion of intellect, attended with great suffusion of the eyes and countenance. We do not entirely proscribe the use of emetics and purgatives in these cases, although we think them rarely useful, and only adapted to the removal of particular accidental conditions of the system. Stimulating diaphoretics may often be employed with advantage, to reduce the heat of the skin by perspiration, and aid the recuperative energies of nature ; but great judgment is necessary in adapting them to the peculiar circumstances of the case.]* Bibliog. and Refer.—Hippocrates, De Morbis, 1. i., cap. 27 ; Epid., 1. vii., cap. 23. -Galen, De Differ. Febr., 1. i., c. 5.—Aitius, Opp. Tetrab., serm. i., cap. 129.—Oriba- sius, Synops., 1. vi., c. 7, 8.—Avicenna, Canon., 1. iv., fen. 1, tr. i., c. i.—Rhazes, Opera, 1. vii., cap. iv. Venet., 1542. —N. Massa, De Febre Pestilenti, Petechiali, &c. Venet., 1556, in Halleri Bib. M. Pr., vol. i.— W. Bulleyn, Dialogue of the Regiment against the Fever, &c. Lond., 8vo, 1564. —A. de Torres, De Febris Epidem. et Novae quae Latine Puncticulans, vulgo Tavardillo et Puntos dicitur, Natura, Cognitione, et Medela. Burgos, 1574. Vide Halleri Bibl. M. Pr., vol. ii., p. 150.-7. Fernelius, De Patholog., 1. iv., cap. 18.—Theraus, De Feb. Purpurea., Epid. et. Contag., Svo. Paris, 1578.—Fracastorius, De Morbis Contagiosis, 1. ii. et iii., passim.—/. Coylterus, De Febre Epid. et Con- tagiosa, 1. ii.,4to. Paris, 1578.—Salius Diversus, De Febri Pestil. et Petech., 4to. Bonon., 1584.—Roborelus, De Pe- ticulari Febre, An. 1591. Vag. Trid., 1592. — Wittich, De Febre Epid. Malign. Petech., 8vo. Leipz., 1592.—/,. Mercatus, De Essentia, Causis, Signis, et Curat. Febr. Malig. Bas., 1594. — P. A. Caprih, 1. iii. De Febribus Putridis in Genere et Specie. Ferrar., 4to, 1591.—V. Bah duli, Nova Febr. Malign. Curand. Ratio., 12mo. Venet., 1612.—B. Brunner, Consilia Medica, Nos. 42, 43, 4to. Hals, 1617.—T. Burserius, De Febre Epid. Petechiali, &c, 8vo. Leips., 1621.—J. C. Rhumelius, Hist Morbi qui ex Castris, [Path. Anat., p. 29, Note.] II [Arch. Gen. de Med., Ju»e, 1839. Med. Chir. Rev., 1836. Am. Journ. Med. Sci., May, 1836.] ir [Lond. Med. Gazette, June 11, 1839. Med. Chir. Rev., On., 1837.] ** [Cat. of Coll. of Surgeons, Dublin Mus., p. 61, b. 600.] genital peritonitis is also a frequent occurrence, according to Billard (Mai. des Enfans) and Duges (Rcch. Sur les Mai., ike ,des Nourcau-nis, Paris, 1821). See a most elaborate paper on this subject by Dr. Simpson, in Ed. Med. and Surg. Journ., Oct., 1838, who has presented numerous cases of this accident in the new- born. See, also, Diet, de Med., vol. xv. (Desor- meaux) ; Morgagni, De Sed., &.C., ep. 67; Journ. Gen. de Med., vol. cii., 1828; Cruveilhier, liv xv., p. 2; Andral, An. Path., vol. ii., p. 737; Guy's Hospital Reports, Xo. V. Ascites is some- times congenital, as well as anasarca and hy- drothorax. See Duges, in Mem. de VAcad. R. de Med.. vol. i. ; Journ. de Med. Chir. el Pharm., vol. xvii., p. 180; Cruveilhier, An. Path., liv. xv., obs. 4, 5, 2 ; Arch. Gen. de Med., vol. viii., p. 383 (M. Ollivier d% Angers), case of encisted dropsy of remarkable size. The liver has been found absent, small, or double, softened, indurated, lacerated, or con- taining pus, granular tubercles, tophi, &c. For a case where it was entirely wanting, consult Am. Journ. Med. Sci., Nov., 1839 (Kieselbach). For an instance of double liver, see Morgagm, ep. 48-55. For other morbid conditions of this viscus, see Monograph " On Diseases of the Fcetus," in Am. Journ. Med. Sci., vols. xxvi. and xxviii., by W. C. Roberts, of New-York, to whose learned research we are much indebted in drawing up the present notice. To the same elaborate article we refer for congenital patho- logical states of the gall-bladder, spleen, &c] Bibliog. and Refer.— Deuttel, De Morbis Fcetnm. Hals, 4to, 1702.—Hoogeven, Tractatus de Fcetus Htimani Morbis, 8vo. L. B., 1784 —Baumes. Traite de l'lctere, ou Jaunesse des Enfans. 8vo. Paris, 1606.—Stewart, Trans. of Med. and Chirurg. Society, vol. v., p. 144.— Lawrence, in Ibid., vol. v., p. 165.—Hey, Ibid., vol. vii., p. 536.-CAew- sier, in Diet, des Sciences Med., t. xvi., p. 50, et t. ixxiv., p. 232.—Murat, in Ibid., torn, xvi., p. 49.— Veron, Nouv. Bibliolh. Medicale, July, 1826, p. 301.—Bracket, Jimrn. Gener. de Med., Jan., 18-28.—Desormeaux, Diet, de Med., t. xv., p. 396.—Lobstein, Repert. d'Anat., &c, t. i., p. 28, 141.—Stratford, Journ. des Progres des Sciences Med., t. xvii., p. 266.— V. Andry. in Ibid., t. i., N. S., 130— Rossi, in Ibid., t. iv., p. 119.—Tonnele, in Ibid., t. xiv., p. 251.— Breschet, Diet, de Med., t. 1.—Allonneau, Nouv. Bililioth. Med., t. ix., p. 363.—Geof. Saint-Hilaire, Archives Gener. de Med., t. ix., p. 41.—Kilian, in Ibid., t. xvi., p. 564.—Du- puytren, in Archives Gen. de Med., t. xiii., p. 63, et t. xvi., p. 562 ; et Repert. Gen. d'Anat., &c, t. ii.,p. 131 (Congen- ital luxation of femur).—P. S. Denis, Recherches Patholog. sur Plusieurs Maladies des Nouveaux-nes, 8vo. Commer- cy, 1826.—C. Billard, Traite des Maladies des Enfans Noo- veaux-nes, «fcc, 8vo. Paris, 1832, 2d edit.—A. Colson, Ar- chives Gen.de Med.,t. xviii., p. 24.—Carus, in Ibid.,t. xvi., p. 444.— Velpeau, in Ibid., t. vi., p. 135, 403, 584, et t. xv., p. 626.-^1. Duges, Diet. Med. et Chirurg. Prat., t. viii., p. 290. [Ad. Bibliog. and Refer. —Licetus (F.), De perfect*. constitutione hominis in utero, etc., 4to. Patavii, 1616.— Alsaro Della Croce (V.), Disquisitio generalis ad hisionam fcetus emortui ncmimestris, etc., 4to. Roms, 1627.—Riola- nus (J.), Fcetus Historia, 8vo. Parisiis, 1628.—Fredericus (J. A.), Tvuvaaua larptKov fcetum quo ad principia, par- tes communes et proprias, differentias, morbos et symp- tomata, eorumque, curationem offerens atque exponens,4to. Jena", 1658. — Valenlini, De morbis embryonem. Giessi, 1*04. — Storch, Kinderkrankheiten, Eisenach, 1750—Sc- ct'n (J. A.), De fcetu hydropico, 4to. Basila, 1751. —.fa- ger, Observationes de Fcetibus recens natis jam in utero mortuis, &c, 4to. Tubing*. 1767. — Raulin. Traite des maladies des Enfans. Pans. 1768.—Gruner, De .Navorum originibus. Jtnie, 1778.—Zierhold, De notabililius qnibus- dam qua fcetui in utero contingere possunt. Hal*, 1778.— Englehart. Dissertatioinaug. med. sistens morbos hominum a prima conformatione usque ad partum, 4to. Jens, 1792. —CEhler, Prolegomena in embryonis humani pathologist. Diss, inaug. Lipsi*, 1815. Joerg, Zur Physidlogie und Pathologie des embryo. Lipsia;, 1818.—Osiander, Hand- buch der Entbindungskunst. Tubingai, 1819.—Seeligmann, Dissertatio de morbis fcetus humani. Erlangen, 1&20.— Zuccarini, Zur Beleuchtuni: der Krankheiten der mcnschli- chen Frucht. Erlangen, lb21.— Veron, Observations sur FUXGOID DISEASE—Description. 1243 Ins milalies des Enfans. 8vo. Paris, 1825.—Ibid., Altera- tions pathologiques deverses trouvees sur des enfans nou- veaux-nes. See notice of report made on this memoir to the Acad. R. de Med., April 26,1825, and the discussion, in Arch. Gen. de Med., viii., 129, and in Ferrussac's Bulletin des Sc. Med., v., 271. — Prosper (S. D.), Recherches de Anat. et de Physiol, pathologique sur plusieurs maladies des enfans nouveaux-nes. Paris, 1826.—Hufeland, Die Krank- heiten der Eugebornen und die Vorsorge, n mire fluid, the same quantity was neulnsned by j or I drachm of the acid. According to BERZELIOs, bile contains 9(141 per cent, of water ; 800 percent, biliary matter with fat ; with a small quantity of mucus and salts of soda and lime. Dr. Pijout's ainlvsis corresponds very nearly to that of Berzelius. Thenard, in l.-'li, first dis- covered two new sunshines in bile, picromel and resin. In 1000 p irts he found ->T5 6 to be water; 30 ntbiliary resin; 75 4 of picromel; 5 of yellow colouring matter; andasmall proportion of salts of so it. The associated ailments, with some of which it often stands in the relation either of cause or of effect, are chiefly indigestion, constipation, diar- rhoea, jaundice, colic, hypochondriasis, agues, rheumatism, gout, herpetic and other cutane- ous affections, enlargements of the spleen, asth- matic seizures, dropsy, and palpitations or oth- er irregular actions of the heart. I have often had occasion to observe that, when any of these complaints was attended by the symptoms char- acterizing this affection, if a purgative succeed- ed in procuring copious bilious evacuations, a very beneficial effect speedily followed. In many of these morbid associations a very gen- tle aperient has produced a very violent opera- tion, but the result has always been most salu- tary. A lady was subject for some time to palpitations, intermissions of the pulse, with great uneasiness at the praecordia. Various opinions were given as to the nature of the dis- ease. Having been consulted, I observed sev- eral of the symptoms indicating accumulations of bile on the biliary passages. A moderate dose of calomel, to be taken at bedtime, and a mild purgative draught in the morning, were prescribed. Violent catharsis followed, and the disordered action of the heart disappeared. In 1822, I was requested by a practitioner to see a patient with him labouring under a severe attack of asthma. He had been purged, but without relief. I inferred from the symptoms that accumulations in the biliary passages had favoured the accession of the seizure; and therefore prescribed, in addition to other means, five grains of calomel, with one of ipecacuan- ha, and five of the extract of henbane, to be given at night, and a stomachic aperient in the morning. The former of these procured an irruption of acrid bile into the duodenum to such an amount as to occasion violent cholera, the morbid bile, in passing through the rectum, occasioning severe scalding and excoriation around the anus. A military officer, who had 4 GALL-BLADDER—Excessive Distention op. suffered several attacks of ague, was seized with it in London, during an easterly wind in March. The practitioner who attended him had prescribed purgatives, and the sulphate of quinine, without benefit. I recommended a bolus to be given at bedtime, containing twenty grains of calomel, five of James's powder, and three of camphor, in conserve of roses ; a pur- gative draught in the morning, and persistence in the use of quinine. Before the purgative draught was taken, violent bilious purging came on, and he had no return of the ague. I could adduce, if it were requisite, numerous instan- ces illustrative of the importance of attending to the association of the morbid state now un- der consideration with other ailments. I know of no disordered condition which so generally predisposes, or so frequently gives occasion to other and more severe diseases as this. 15. iv. The Remote Causes of accumulations of bile are numerous, and not fully recognised by writers. From my own observations in this climate, as well as in warm and other countries, I believe that they will be found to be the following: (a) Predisposing.—A warm, moist, low, and miasmatous climate; mental depression, anxiety, and grief; general debili- ty, and weakness of the digestive organs ; the bilious, melancholic, or phlegmatic tempera- ments ; sedentary occupations, indolence, and confinement; insolation; too full living, and the use of too much animal food; indulgence in wine or spirituous liquors ; and venereal ex- cesses.—(b) The exciting causes are, the sudden or protracted abstraction of the heat of the body, especially when in an inactive state, as sleeping with too few clothes, or in a damp bed, and the ingestion of cold drinks or ices ; neglect of the bowels ; and agues, or previous disorder of the biliary apparatus. 16. v. Treatment.—The means to be employ- ed for the removal of this disorder are so evi- dent as scarcely to require remark. Cases, however, occur in which some discrimination as to the choice of medicines for the evacua- tion of the accumulated secretion is necessary. In general, the milder purgatives should be first prescribed; and, if these fail, the more ener- getic may be employed. It often happens, par- ticularly when the bile has become inspissated, or when the gall-bladder and ducts have had their contractility much impaired by over-dis- tention, or by any other cause, that the repeat- ed exhibition of chologogue purgatives is ne- cessary. But in other cases, especially when the bile has acquired acrid qualities, the gentler means will be the least likely to produce the severe effects often following the first dose of a purgative, after the disuse of this kind of medicine for some time. Accordingly, five grains of blue pill, or of Plummer's pill, may be given at bedtime, and a mild aperient draught the following morning. The evacuations should be inspected, and the repetition of these, or the selection of more active means, determined upon from the appearances they will present. If it should be necessary to repeat the purga- tive frequently, the mercurial ought to be given with caution, or only on each second or third night, and either of formulae 205, 266, or of the following, should be taken on the following morning, and on the intervening nights, until all bdiary collections have been removed : No. 230. ft Infusi Senna Comp., Infusi Gentians Comp., U 3vj. ; Potassa: Sulphatis 3j.—Jss. ; Extrncti Taraxaci Jss.—3ij. ; Tinct. Cardamom. Comp. ~jsa. M. Fiat Haus- tus. horft somni vel primo manp sumendus. No. 231. ft Infusi Calumba;, Infusi Senna; Comp., At Jvjss. ; Sode Carbon., gr. xv.—3j.; Entr. Taraxaci 5)i).; Tinct. Cardamom. Comp. 3jss. M. Fiat Haustus ut supra sumendus. No. 232. ft Potassa Bitart. in pulv. ?ss.—-vj.; Con- feet. Sennae Jss. ; Sirupi Zingibens q. s. ut fiat Electuarmm molle, cujus dimidium sumatur hora somni, vel mane noc- teque. 17. The above are generally sufficient to ac- complish the ends in view. But sometimes they fail, although repeated, to procure a suffi- cient evacuatiou of bile, or to remove all the symptoms depending upon collections in the bil- iary passages. When this is the case, a full dose of calomel, with James's powder or cam- phor, or ipecacuanha, or with the compound camboge pill, or the compound extract of colo- cynth, may be given at night; and either of these draughts, or a solution of neutral salts, in the morning. An emetic is often beneficial in such circumstances, before these measures are resorted to. When there appears reason to believe that the accumulation of bile arises from active congestion of the duodenum, par- ticularly when the symptoms of inflammatory indigestion are present, or when the indications of spasm in the ducts seem to exist, calomel is generally necessary, and it may be repeated with advantage. The combination, also, of ipecacuanha or antimony with the purgative taken at night promotes the action on the bili- ary organs. In some obstinate cases, when it was necessary to repeat the purgatives fre- quently, I have given colchicum in either of the above draughts with benefit. Besides these, frictions with stimulating liniments over the right hypochondrium and epigastrium, or a blis- ter, the nitro-hydrochloric acid lotion, or the emplastrum ammoniaci cum hydrargyro, in the same situation, may be prescribed. A healthy air, or change of air, regular exercise, particu- larly horse exercise, early hours, and the use of the Cheltenham mineral waters, or the arti- ficial mineral waters of Seidschutz or of Pullna, with attention to diet, will materially promote the action of the biliary apparatus. The treat- ment is, in other respects, similar to that advi- sed in the articles on Constipation and Indi- gestion. III. Excessive Distention of the Gall-blad- der. 18. i. It is not often that the accumulation of bile in the gall-bladder is so great as to give rise to an external tumour, as its discharge into the duodenum generally occurs before it reaches this extent. But cases sometimes are seen in which a very distinct tumour is formed by the distended gall-bladder in one of the fol- lowing situations : 1st. In the epigastric region, and a little towards the right side; 2dly. Im- mediately below the cartilaginous margins of the right ribs; 3dly. Lower in the hypochon- drium, and directed either downward, or up- ward, or even backward, but most frequently rising into the epigastrium; and, 4thly. De- scending down either towards the umbilicus, or to the crest of the ilium, or between these situations. The distention of this viscus arises, (a) from inflammation and tumefaction, or thickening, &c, of the coats of the common duct, occasioning more or less narrowing or GALL-BLADDER—Diagnosis. 5 complete obstruction of its canal; (b) from similar lesions, or tumours, in the duodenum, implicating the termination of this duct; (c) from the arrest of a biliary calculus in the same situation; (d) from tumours in the pancreas, pylorus, or adjoining parts, or even in the liver itself, pressing upon this duct; (e) from the en- tire obliteration of the duct, in consequence of cither of the foregoing lesions ; and (/) possi- bly from spasmodic constriction, or from the accumulation of thickened bile or mucus in the canal. Of these five alterations, all but the last have been observed by me in post-mortem examinations. The last, very probably, has existed in some of the cases in which the tu- mours have disappeared with more or less rapidity. 19. The tumour, thus formed by an exces- sively distended gall-bladder, may, a. continue during the remaining life of the patient; 0. or disappear after a longer or shorter time, its subsidence being either slow or rapid. This latter event may proceed either from the re- moval of the obstruction in the common duct, whether this have been spasm, inflammation, or any of the more mechanical obstacles just mentioned, or from the gradual absorption of more or less of the bile in the bladder. When absorption of the contents of this viscus pro- ceeds, an additional quantity not passing into it, the tumour will disappear slowly and gradu- ally. Instances have occurred, however, in which the coats of the gall-bladder, owing to the great distention, or to the acrimony of the contained fluid, have become inflamed or ulcer- ated, and have subsequently been perforated or ruptured, the contents being effused, either into the peritoneal cavity, giving rise to intense and rapidly fatal peritonitis, or into some other viscus with which the gall-bladder had pre- viously formed adhesions. Cases of this kind have been recorded by Schenck, Bertin, Al- berti, Salmuth, Bonet, Desjardies, Portal^ Frank, Double, and Porral. The accumula- ted bile may even be poured out externally, owing to the adhesion of the gall-bladder to the abdominal parietes and to the inflammation, ulceration, and perforation having proceeded from the former to the surface of the latter. Horstius, Bloch, Amyand, and De Haen have detailed cases of this description. 20. Although calculi lodged in the common duct most frequently occasion distention of the gall-bladder, yet this cause may exist without this effect being observed ; or it may have been present and have gradually subsided. M. Duplay (Jovrn. Hebdomad., t. iii., p. 14) has ad- duced a case in which this duct was complete- ly obstructed by a calculus, the hepatic ducts and their radicles having been much dilated, and yet the gall-bladder was atrophied, and re- duced to a simple canal with thickened pari- etes. Inflammation of the gall-bladder had most probably supervened in this instance, and been followed by thickening and constriction of its coats, with absorption of its contents. M. Petit thinks that inflammatory engorge- ment and tumefaction of the liver is often con- cerned in producing accumulation of bile in the bladder; and that, when the resolution of the inflammation is followed by a copious secretion of this fluid, before the congestion or tumefac- tion and obstruction of the common duct have been removed, the distention of the gall-blad- der will often be excessive. From whatever cause it may arise, the accumulation is often remarkable. In a case related by Mr. Gibson (Edin. Med. Essays, vol. ii., p. 352), the tumour was so large as to reach over to the left hypo- chondrium, to force out the false ribs of both sides, and to occasion great difficulty of breath- ing. The common duct was found, after death, obstructed by concretions, and the gall-bladder contained eight pounds of thick bile. Young (Philos. Trans., vol. xxvii.) found in the body of a middle-aged female a similar obstruction, and nearly the same quantity of thick bile in the gall-bladder. Parallel instances, to which references are made at the end of this article, are recorded by Vesalius, Goldwiz, Huesingek, Hautesierk, Amyand, Vetter, Kraeff, Van SwiETEN, DUVERNEY, PeZOLD, WIEDEMANN, and others. 21. The contents of a distended gall-bladder do not always consist of bile. In rare instan- ces, purulent matter, or numerous biliary con- cretions, have been collected in it. The for- mer has generally passed into it from an ab- scess in the liver, either along the ducts or subsequent to adhesions formed between the external surfaces of the liver and gall-bladder. Morgagni and Fantoni found it distended by air. 22. ii. Diagnosis.—A tumour arising from accumulations of bile in the gall-bladder may be mistaken for an abscess of the liver, or for encysted dropsy, or for a tumour containing hyda- tids ; and, if an opening were made into it, in the supposition of it being either of these, a fatal result would immediately ensue, unless adhesions had previously formed between the gall-bladder and the parietes of the abdomen, which rarely take place. It, therefore, is very necessary to distinguish between these diseases and an excessive distention of the gall-bladder. —(a) The diagnosis between this latter and abscess of the liver, pointing externally, is often difficult. In a case which I had an opportunity of seeing, the surgeon was about to puncture the tumour, when, delay having been suggest- ed, and chologogue purgatives prescribed, the tumour disappeared after a copious discharge of bile. A similar case was lately reported in one of the London Medical Journals. M. Petit, having been consulted in a case that had been considered abscess of the liver, had commenced with the operation for the removal of its con- tents ; but as soon as he had divided the integ- uments the tumour became soft, and instantly afterward subsided. He closed the incision and proceeded no farther, telling the assistants that this occurrence had shown him the nature of the disease, and that copious bilious evacu- ations would soon take place. This directly occurred, and the patient recovered. The symptoms distinguishing between these two lesions are the following: 1. The rapid appear- ance and circumscribed form of the tumour, with manifest fluctuation throughout its extent, when it proceeds from the gall-bladder. 2. The softness and mobility of the integuments over the more prominent parts of the tumour; and the absence of a diffused swelling or hardness at the circumference, and of oedema, or of an emphysematous feel, when it is thus produced. J. Abscess of the liver is consequent upon in- 6 GALL-BLADDER AND DUCTS—Inflammation of. fiammatory symptoms referrible to this viscus. The tumour it occasions forms slowly, is at- tended with great swelling, and tension in the parts adjoining, and is at first diffused, hard, and imperfectly defined. Fluctuation is very obscure, occurs late in the progress of the swelling, and is confined to, the centre, the circumference being hard and tumid. 4. There are always febrile symptoms attendant upon this disease; but they are seldom observed in distention of the gall-bladder, unless inflamma- tion has supervened. 5. Pain in suppuration is pulsatory, in the other it is not, and it gener- ally intermits. 6. Shivering is more frequent- ly present in suppuration, or continues longer, than in distention of the gall-bladder; and it terminates in perspiration, which rarely occurs in the latter. 7. A distended gall-bladder pre- sents more of the appearance of a deep-seated encysted tumour than of abscess. — (b) The swelling from encysted dropsy is larger, and the fluctuation more distinct than from a distend- ed gall-bladder.—(c) The same remark, how- ever, does not apply to the encysted tumours that contain hydatids. Between both these and distention of the gall-bladder the diagnosis is often very difficult, unless the appearances of the evacuations and of the skin are closely observed. In the latter the stools are devoid of bile., are white or clayey, &c.; the urine is very dark, loaded, and clouded ; and the skin discoloured or jaundiced. In the former the stools are rarely without bile, and the other symptoms are seldom observed, as there is no interruption of the passage of this secretion into the duodenum, nor suppression of the function. 23. iii. The Treatment of excessive distention of the gall-bladder should not be materially dif- ferent from that advised for the common oc- currence of impaired action of the biliary pas- sages (y 16). The alkaline carbonates, the spirits of nitric aether, and the extract of tarax- acum, in liberal doses, either in camphor julep, or in the medicines prescribed above (v 16), or in the decoction of taraxacum, will often be serviceable, especially when the use of them is steadily persisted in, is varied according to cir- cumstances, and is aided by the external reme- dies already mentioned (y 17). When the dis- tention seems to arise from the arrest of biliary concretions in the common duct, or, indeed, from any other cause, the liquor potassae, cas- tile-soap, the biborate of soda, antimonials in small doses, anodynes, the warm bath, and ole- aginous aperients, as olive oil, &c, will be the most useful. Emetics are dangerous ; but lax- atives, mild purgatives, and aperient enemata are beneficial, and should be continued from time to time. In all cases of biliary obstruc- tion the means enumerated at another place (see art. Concretions—Biliary, v 14, et seq.) will be very appropriate. The most suitable beverages are, the common imperial drink, or a solution of equal parts of the bitartrate of pot- asn and biborate of soda, dissolved in a weak decoction of marsh-mallows, or of taraxacum, with a little orange peel, &c.; or warm whey, or soda water, or spruce beer. The factitious waters of Seidschutz, or of Geilnau, or of Ma- rienbad, or the mineral waters of Seidlitz, of Leamington, or of Scarborough, are often of service both in this and other forms of biliary | obstruction. But I believe that there is no mineral water more beneficial than that most common of all mineral waters, namely, sea water, when it is taken in sufficient quantity, and persisted in for a reasonable period. IV. Inflammation of the Gall-Bladder anm Ducts. Hepatitis Cystica, Sauvages ; Chole- cystitis, Hildenbrand. Classif.—II. Class, III. Order (Author). 24. Defi.v—Deep-seated acute pain in the epi- gastric region, extending to the right hypochon- drium, and backward, generally with vomiting of a greenish bile, frequently with jaundice, and al- ways with symptomatic fiver. 25. i. The Symptoms of inflammation of the gall-bladder or ducts are extremely fallacious. This disease may be either acute, sub-acute, or chronic; and, in either of these states, it is generally consecutive of inflammation of the concave surface of the liver, or of obstructions of the ducts, or of the irritation of biliary con- cretions ; and hence its approach is slow and insidious, or the symptoms attending it are merely an aggravation of those produced by the antecedent disorder. This is especially the case when it occurs in a chronic or sub-acute form. Chills or rigours may or may not occur; but they are generally preceded by pain, more or less severe and acute, in the situation men- tioned above. Vomiting is frequently present, and the matters ejected are often greenish. There is great tenderness at the epigastrium, and pressure is apt to excite vomiting. Severe colicky pains are felt in the upper regions of the abdomen ; and jaundice sometimes appears suddenly. The attendant fever is characterized by a small or constricted pulse, by evening ex- acerbations, by a very dark, turbid, and scanty urine, and by thirst. The stools are generally devoid of bile. These are the most constant symptoms of inflammation of this viscus ; but they are not altogether to be depended upon, for they are usually present in hepatitis, and even in duodenitis or gastritis. Another cir- cumstance which adds to the difficulty of diag- nosis, besides its mode of accession, is its fre- ] quent complication with these diseases, or with dropsical effusion, especially in the abdominal cavity. But inflammation of the gall-bladder or ducts is often consequent upon excessive distention ; and, when this is the case, the characteristic symptoms commonly follow a more or less distinct tumour in some one of the situations I have noticed above; and the nature of the complaint is thereby made manifest; jaundice, and white stools, with very dark urine, being then seldom or never wanting. 26. ii. Changes consecutive of Inflammation of the Gall-bladder, &.c.—These are various. I , shall take a brief view of the most common.— (a) Suppuration, ulceration, and softening are not infrequent. The gall-bladder may be almost filled with pus from inflammation of its internal surface ; but the admixture of pus with the bile and ulceration are more common. Cases of this kind have been noticed by Vetter, Mor- gagni. Amyand, Walter, Morand, Frank, Bail- lie, Scemmerring, Martin Solon, and Andral. The ulceration may pass into perforation, or even rupture, without any very considerable distention of the viscus having previously oc- curred, the bile being effused in the peritoneal cavity or into some adjoining viscus in the man- GALL-BLADDER AND DUCTS—Spasm of. 7 ner already noticed (v 19). In cases of ulcer- ation and rupture, softening is not often absent; and probably it favours the latter occurrence — (b) Gangrene is a very rare occurrence. I have seen it mentioned only by J. P. Frank—(c) When inflammation either commences in, or extends to the more external coats of the gall- bladder, adhesions of it take place to adjoining parts. It has been seen adhering to the peri- toneum, by Bloch, Petit, &c. ; to the omen- tum, by Walter ; to the duodenum, by Ludwig, Frank, Portal, Reynaud, myself, and others ; to the colon, by Walter, &c. ; and to the liv- er, by Annesley, myself, and several writers. These adhesions may exist either with or with- out distention, or the presence of biliary con- cretions ; but either or both are often observed or have manifestly existed at one period or oth- er of the disease.—(d) Thickening of the coats of the viscus is evidently a consequence of in- flammation in some one of its grades. It has been remarked by Schmalz, Walter, J. P. Frank, Sosmmerring, Andral, and myself. Stoll and Leveillie have noticed the thick- ening, conjoined with a cartilaginous induration. —(e) Ossific deposites in its coats have been found by Rhodius, Walter, Murray, Grand- champ, Moi.linelli. Baillie, and Andral. 27. There are various other alterations of the gall-bladder which do not necessarily arise from any grade or mode of inflammation, and which may be noticed at this place.—a. The gall-blad- der may be hypcrlrophied in respect both of its capacity and the thickness of its coats. The simple distention arising from obstruction of the common duct cannot be justly called hy- pertrophy, although some French pathologists have thus denominated it. — ft. Atrophy, or wasting of it, is not uncommon, even as a con- sequence of chronic inflammation affecting ei- ther itself or the ducts, particularly the cystic duct. Instances of this change are recorded by Morgagni, Walter, Rossi, So:mmerring, Hufeland, and Andral. In these cases the passage of bile into or from it having been pre- vented, the portion of this fluid contained by it has been absorbed, and the functions of the vis- cus having ceased, its structure has gradually wasted until it has almost disappeared.—y. In- stances in which the gall-bladder has been ei- ther congenitally wanting, or has disappeared from antecedent disease, have been adduced by Fernelius, Marcellus Donatus, Schenck, Hu- ber, Morgagni, Jaeger, Ludwig, Sandifort, Zeigler. Baldinger, Lemery, Boulet, Tar- gioni, Tozzetti, Littre, Wiedemann, Otto, Dkndy, &c. That this viscus may entirely dis- appear in the same manner as it becomes atro- phied, may be admitted. When only atrophy has occurred, there is still some little cavity left; but when the bladder has disappeared, the cystic duct is reduced to a fibrous chord terminating in a mass of cellular tissue.—e. The coats of the gall-bladder may, moreover, be infiltrated with serum, or contain tuberculous or calcareous matters. 28. iii. The Ducts—the hepatic, cystic, and common—are liable to all the changes noticed with reference to the gall-bladder, to disten- tion, obstruction, inflammation, thickening, ul- ceration, softening, perforation, rupture, hy- pertrophy, atrophy, obliteration, etc. The symp- toms, however, attending these lesions during life are very equivocal. The symptoms pro- ceeding from inflammation closely resemble those enumerated as indicating inflammation of the gall-bladder. Most of the changes to which the ducts are obnoxious are the effects either of concretions obstructing and irritating them, or of inflammation having extended to, or been excited in them. Inflammation, wheth- er it extends to them from the duodenum, or from any other part, or arises from the acri- mony of the secretion passing along them, is equally accompanied by swelling of their coats, and by more or less complete obstruction of their canals, often with softening or ulceration. Constriction or narrowing from this cause has been observed by Bonet, Hoffman, Mead, Bi- anchi, Bruning, Crichton, Baillie, Andral, &c, and complete obliteration of one or other of them has been remarked by myself and most of the writers referred to in this article. Os- sification of them has been seen by Bonet and Sosmmerring. Dilatation, principally of the common and hepatic ducts, is recorded by Schenck, Duverney, Morgagni, Walter,Rich- ter, Duplay, Andral, and Todd. Rupture of these ducts has occurred to Wolff, Andral, and others. References to all the foregoing lesions will be found at the end of the article. 29. iv. Spasm of the Bile-ducts.—The exist- ence of this disorder has been presumed rather than proved. Without denying, however, its occurrence, particularly when acrid bile, or gall- stones, are passing along the ducts, I believe that it seldom takes place unless from these causes, and in connexion with inflammatory irritation. The instances of sudden appear- ance of jaundice sometimes met with have been imputed to spasm of the ducts ; but, al- though spasm may occur independently either of inflammation or of biliary concretions, yet the pathological state producing jaundice is most frequently seated in the liver itself. The affection, therefore, which has been generally ascribed to spasm of these canals should be rather imputed to either of the above causes, or to any two of them : 1st, to inflammatory irritation without calculi; 2dly, to the irritation produced by calculi; 3dly, to irritation caused by acrid bile; 4thly, to spasm chiefly; and 5thly, to either of the foregoing in connexion with spasm. It is hence most difficult to dis- tinguish spasm from inflammation of the ducts, or either of these from the passage of gall- stones. Indeed, the symptoms indicating the latter are in no respect different from those at- tending upon most of the cases generally im- puted to spasm. A sudden, sharp, deep-seated, and severe pain at the pit of the stomach, dart- ing back to the right side of the spine, or to the lower angle of the right shoulder-blade, and to the hypochondrium, occurring in paroxysms, and often followed by rigours, coldness of the extremities, &c, are felt in both. Nausea and vomiting are sometimes also present. When, however, the disorder proceeds chiefly from spasm, pressure gives relief of the pain in the epigastrium, as well as of the colicky pains usually felt at intervals in the abdomen. The patient commonly turns upon his belly, or lies partly on the right side, and partly on the abdo- men. This, in connexion with the slight affec- tion of the pulse, chiefly distinguishes spasm from inflammation of the ducts. In other re- 8 GALL-BLADDER AND DUCTS—Treatment—Bibliography and References. spects the symptoms are nearly the same as those stated to indicate the passage of the gall- stones.—(See art. Concretions—Biliary, y 8.) 30. v. Treatment.—Inflammation of the gall- bladder and ducts should be treated in a nearly similar manner to other inflammations, but with reference to the organization and functions of the part. The first intention should be, to re- move the inflammation ; the second, to procure a free and healthy flow of bile into the duode- num. Blood-letting, both general and local, is always requisite; and generally tends to the fulfilment of both indications. Immediately after the first blood-letting, a full dose of calo- mel—from five to twenty grains—according to the age and strength of the patient, with James's powder and opium or hyoscyamus, may be given with few exceptions. Experience has proved the propriety of exhibiting one or two doses of this medicine in cases where these parts have been either partially or chiefly implicated, and the experiments of Mr. Annesley have demon- strated the influence of a large dose of calomel in diminishing inflammatory irritation of the stomach and duodenum : an effect which, if produced in these viscera, will probably extend to the gall-ducts. If a repetition of the bleed- ing should be necessary, the calomel, antimony, and opium may be repeated immediately after- ward, as this combination has a most decided effect, when thus exhibited, in diminishing vas- cular action, and in equalizing the circulation. Mild aperients and cathartic enemata may subse- quently be given ; and, having thereby procured evacuations, medicine of a deobstruent and relax- ant kind should be prescribed. The alkaline car- bonates with taraxacum; the biborate of soda, in the decoclum althaa, with small doses of ipecac- uanha, and of the powder or the extract of the leaves of belladonna; and the nitrate of potash or hydro-chlorate of ammonia, in camphor mix- ture, with large doses of the spirits of nitric other, are the most appropriate medicines ; but they should be given in repeated doses, and so as not to offend the stomach. 31. Of the external applications, the most effi- cacious are the warm terebinthinated embrocation, warm poultices, fomentations, and afterward a plaster consisting either of the emplastrum am- moniaci cum hydrargyro, or chiefly of the extract of belladonna and camphor, according to the pe- culiarities of the case. Having removed in- flammation, and relieved the more urgent symp- toms, by these or similar means, a due flow of bde into the duodenum should be promoted by small doses of blue pill, or of Plummer's pill, the liquor potassae, or the carbonates of soda or potash, or the biborate of soda, or the ace- tate of potash, or the extracts or decoction of taraxacum or of chelidonium, or the aethers, &c, variously combined. A gentle action on the bowels, by emollient and oleaginous medi- cines, should be continued for some time. If pain of a spasmodic kind recur, belladonna, or hyoscyamus, or opium, or colchicum may be given with these ; and if the irritation seem to be owing to the presence of gall-stones, the combination of the spirits of turpentine, with sulphuric aether, as advised by Durande, Straub, Witting, Quarin, and others, or with alcohol, as recommended by Percival, or with the spirits of nitric aether, as directed by Wolff, may be tried. An anodyne may also be given with either of these combinations, especially hyoscyamus, or belladonna. Colchicum, with the alkaline carbonates, has proved of great benefit in some cases in which I believed the biliary passages to have been implicated in the inflammation of the associated viscera; and hydrocyanic acid, given in full doses with olive oil, or with almond oil and camphor julep, has afforded great relief where there was every reason to suppose that gall-stones or spasm was the cause of suffering. The treatment in other respects, as well as the diet and regimen of the patient, are altogether the same as are fully detailed in the articles Concretions—Bil- iary, and Jaundice. Bibliog. and Refer.—Attius, Tetrab. iii., serm. i., c. 2.—Fernelius, Pathol., 1. vi., c. 5.— Viscerus, De Folliculi Fellis Nat. et Affectibus. Tub., 1582.—Schenck, Observ., 1. iii., c. 2, obs. 08, 75-—Rhodius, Observ., cent, iii., No. 3. —Salmuth, Cent, i., obs. 3.—Marcellus Donatus,\.\i., c. 2, p. 616.—J. J. Nosset, Delineata Bilis Abund. Dominant is Idea, 12mo. Freib.. 1684.—S. Claramonteus, De Atra Bile, ., p. 227- 238.—J. Frank, Acta Instit. Clin. Viln., Ann. i.,p. 108.— Fuchs, in Doering, vol. i., p. 166.—Michatlson, in Ibid., vol. i., p. 167.—Shcrwen, in Duncan's Ann. of Med., vol. vi., p. 399.—J. Gibson, A Treatise on liilions Diseases, and on the Effects of Quassia and Natron, &c , Svo. Lond., 1799. —Percival, Essays, vol. ii., p. 110.—DesjaroHes, in Journ. de Med., t. xxii., p. 368.—Double, in Ibid., t. xxii., p. 363. — W. Saunders, A Treatise on the Diseases of the Liver, and on Bile and Biliary Calculi, &c, 4to ed., p. 117.—R. Powell, Observations on the Bile and its Diseases, 8vo. Lond., 1800.—Sandifort, Tabul. Anat., 1804, p, 26.-7*. Jameson, Treatise on Cheltenham Waters and Bilious Dis- eases, 8vo. Lotd., 1804.— Crichton, in Med. and Pnys. Journ., vol. vi., p. 29— Hufeland, Journ. der Pr. Heilk.. hw viii., p. 114-116.— Schmalz, in Ibid., b. iv., p. 522.—Wiede- mann, in Ibid., b. iii., p. 383.—Treuner, in Stark, N. Ar- chiv., h. ii., p. 90.—Baillie, Morb. Anat. edit, by Wardrop* vol. ii., p. 214.—Sazmmerring, Germ. Trans, of Baillit'* GANGRENE—Pathology. 9 Morbid Anatomy, p. 141 ; and in Blumenbach, Med. Bibli- oth., vol. iii., p. 92.—Baldinger, N. Magaz., b. i., p. 273.— Ross:, in Giorn. Fisico Med. di BrugnateHi, vol. i., p. 90.— Heusinger, in Horn, Archiv., Nov., 1811, p. 463.—Mare- schal, Remarques sur les Mai. de la Vesicule Biliaire, 4to. Paris, 1811.— Otto, Handb. der Path. Anat., 1814.—Pem- berton, On the Dis. of the Abdom. Viscera, ch. iii.—Patis- sier, in Diet, des Sciences Med., t. lvii., p. 370.—O'Ryan, in Journ. Univers. des Scien. Med., t. xiii., p. 113.—Chomel, Nouv. Journ. de Med., t. i.—Martin Solon, Bullet, de la Faculte de Paris, 1821, No. 11.—H. Wolff, Journ. des Progres des Sciences Med., t. xiv., p. 245 ; et Archives Ge- nerates de Med., t. xx., p. 108 — Andral, in Ibid., t. vi., p. 161 ; et Rev. Med., t. iv., p. 301.—Todd, in Dublin Hosp. Reports, vol. i., p. 325.—Duplay, Journ. Hebdom. de Med., t. iii., p. 14.— Ollivier, in Archives Generates de Med., t. v., p. 196.—Amussat, in Ibid., t. xvi., p. 286.—Follet, in Ibid., t. xvi., p. 622.—Godart, in Ibid., t. xx., p. 287.—An- nesley and Author, Researches on Dis. of India, &c, vol. i., p. 326.—G. Andral, Clinique Medicale, &c, t. iv., p. 324; et Anat. Pathol., Trans, by Townsend and West, vol. ii., p. 602.—Catal. of Preparat. in the Army Med. Depart., &c, p. 115, 119.—Campagnac, in Journ. Hebdom. de Med., t. ii., p. 204.—Porral, in Ibid., t. iv., p. 473.—Reynaud, in Ibid., t. iv., p. 490.—W. Twining, Clinical Illustrat. of the Diseases of Bengal, GANGRENE—Treatment. 25 form coagulable lymph, by which disorganiza- tion will be arrested. Although the state of the circulating fluid is overlooked in these views, yet they are correct in the main, and form the basis of a rational and successful prac- tice in this and several other maladies. 69. ft. Before I proceed succinctly to state the practice I would recommend conformably with these opinions, and with the results of ob- servation, I shall briefly notice the constitu- tional means advised for this disease by some experienced writers. On the first manifesta- tion of hospital gangrene, emetics are recom- mended by Pouteau, Dussaussoy, Briggs, Thomson, and Hennen, and are evidently of service at this period, when there are signs of biliary derangement. Blood-letting is consider- ed injurious or productive of little benefit by Blackadder, Thomson, and Boggie, while Dr. Hennicn and Mr. Welbank consider that mod- erate depletion is serviceable early in the at- tack, and in strong plethoric persons ; and that the risk of the disease attacking the lancet wound may be prevented by accurate closure, and by allowing the bandage to remain undis- turbed until the cicatrix is completely formed. Purgatives are directed by Dr. Boggie and oth- er writers, but they should be warm and sto- machic, or conjoined with tonics, stimulants, or aromatics, and exhibited early in the dis- ease. It is chiefly after morbid secretions have been evacuated by the early exhibition of emet- ics and purgatives that advantage from tonics and stimulants will be most apparent; and it is probably from an insufficient attention hav- ing been paid to this circumstance that so much difference of opinion exists as to the pro- priety of using these latter remedies. 70. Cinchona alone, or in various states of combination, is praised for its good effects in this disease by Boyer and numerous expe- rienced writers, while Hennen and Welbank consider that it is injurious. It is recommend- ed in conjunction with the alkaline carbonates by Van Wy and Saviard; and with camphor, by Flajani. Camphor is much used in this form of gangrene by Continental practitioners. Pouteau, Conradi, Wenzel, and Ontyd pre- scribe it in large doses. I have seen much ad- vantage derived from it; but I prefer to give it in the forms of combination to be mentioned hereafter. The arsenical solution is directed by Otto. It may be employed in similar states of constitution to those in which cinchona or sulphate of quinine may be prescribed. Arnica, cascarilla, and various other stimulants and aro- matics are recommended by various authors, but they are useful merely as adjuvants of oth- er more active means. Acids are noticed in favourable terms by Mr. S. Cooper, and sev- eral other writers ; but I have much doubt of any benefit being derived from their internal use. The hydrochloric and nitric acids, or a com- bination of both, promise most advantages of this class of medicines. Of the propriety of exhibiting opiates there can be no doubt; and most writers agree on this point, and differ only as to the period of having recourse to them. Dr. Thomson prefers them in the form of Do- ver's powder. 71. y. From observation of the results of dif- ferent modes of practice in hospital gangrene, rather than from my own actual experience, I would advise the adoption of a practice conso- nant with the views stated above. Having evacuated morbid secretions and faecal accu- mulations by emetics and warm stomachic pur- gatives, and directed a small or moderate blood- letting in such cases only as are attended by excessive action and signs of plethora, I would advise the decoction of bark or the sulphate of quinine in modes of combination appropriate to the peculiarities of the case. If vascular action continue very much excited, the decoc- tion of bark may be conjoined with the nitrate of potash, the solution of the acetate of ammo- nia, and the spirits of nitric aether, or with the hydrochlorate of ammonia and chloric aether. When vascular action presents diminished tone, the sulphate of quinine may be exhibited in the compound infusion of roses, or in the form of pill with camphor. Where the pulse is weak and quick, the evacuations offensive, and the disposition of the gangrene to extend very evi- dent, the decoction of bark should be combined with the chlorate of potash and compound tincture of bark; and if anxiety, pain, or irrita- bility be present, the tincture of opium or the hydrochlorate of morphia may be added. The great frequency of pulse and loaded state of the tongue generally observed in hospital gan- grene, even indicate the propriety of having re- course to these and similar remedies, or to wine in some cases. Regard should also be paid to the previous habits of the patient; and persons addicted to spirituous liquors may be allowed them, but in duly prescribed quanti- ties. If the stomach become irritable, the treatment I have advised above (v 60) may be employed, or spiced wine may be given ; or soda water, spruce or ginger beer, or Seltzer water, may severally be made vehicles of tonic, stimulant, cardiac, or aromatic substances. 72. If diarrhoea appear, and threaten to ex- haust the powers of the constitution, opium, or the compound tincture of camphor, should be given in full doses, with the tonic and antisep- tic remedies already mentioned; or the chlo- ride of lime may be used internally with tonics and aromatics, or with camphor and the warm. spices, or administered in mucilaginous and emollient enemata. If delirium supervene, ex- haustion of nervous power, with or without de- terioration of the circulating fluids, may be in- ferred to exist; and camphor with opium, or henbane, the decoction of bark, with the alka- line carbonates and tincture of serpentaria, wine, and the other remedies recommended for Putro-adynamic Fever, and the low forms of Delirium (see these articles), should be pre- scribed with a decision commensurate with the urgency of the case. Camphor, in order to be beneficial in hospital gangrene, ought to be ta- ken either in frequent or in large doses. If vascular action be much excited, it will be ad- vantageously conjoined with the nitrate of pot- ash, or nitrate of soda, or the alkaline carbon- ates, or other saline refrigerants. If vascular action be weak or impaired, and vital power manifestly reduced, it should be combined with the preparations of cinchona or of serpentaria, or with the chlorides and aromatics. Casca- rilla, cinchona, or arnica may be severally em- ployed in similar forms of combination, appro- priately to the circumstances of the case. | 73. In this form of gangrene especially, proph- 26 GANGRENE—Local Treatment. ylactic measures, founded upon a knowledge of the causes specified above (y 38), should be strictly enforced ; and as soon as the disease manifests itself, the patient should be removed into a well-ventilated and dry apartment, and the mind encouraged by cheering prospects, and by the confidence of the physician in the extent of his resources. The local treatment ought to proceed as will hereafter be noticed, conjointly with the above constitutional means of cure. 74. d. When gangrene follows the bites of serpents, the viper, or other reptiles, the con- stitutional symptoms will then be characterized be depression of vital action and power so ex- treme as to threaten immediate dissolution, and to require the exhibition of ammonia, camphor, capsicum, cajeput oil, and other energetic stim- ulants in large and frequent doses. In cases of this description, recourse should be had to local means (y 78) immediately upon the receipt of injury. 75. ii. Local Treatment.—a. Topical measures ought to be directed with the following inten- tions : namely, 1st. To restore the tone of the extreme vessels in or surrounding the gan- grened or sphacelated part; 2d. To procure the separation of this part as soon as it passes into sphacelation; and, 3d. To prevent the contamination of the circulation and surround- ing tissues by the morbid matters proceeding from its decomposition. Substances calculated to accomplish either of these ends will gener- ally also attain the others. Their application should, however, not be delayed either until the gangrened part pass into sphacelation, or after this result has taken place, but should be brought in aid of constitutional treatment. Be- fore the discovery of the chlorides and crea- sote, numerous substances were recommended to arrest the progress of gangrene, and to fulfil the intentions just stated. In cases of inter- nal gangrene, measures of this description can but rarely be employed. In gangrene of the lungs, however, the inhalation of the fumes of creasote, or of the chlorides, or dilute chlorine, has proved of more or less service. A judicious use of these in external sphacelus is frequently productive of decided benefit, as they fulfil all the above indications. Next to them in effica- cy are the turpentines and the balsams, espe- cially the spirits of turpentine and the Peruvian balsam. When there are much pain and irri^, tability of the part, opium may be added to the local applications. ' Many other substances have been recommended to be used topically in gan- grene, but I must refer to the well-known work of Mr. S. Cooper for a sufficiently detailed ac- count of them. A glance at the opinions of surgical writers on gangrene will readily show that each has been sufficiently disposed to en- hance his own favourite application by depre- ciating those recommended by others, so that the inexperienced practitioner is bewildered amid contradictory evidence on the subject. The substances already mentioned, especially Labakraque's fluid, strong solutions of the chlo- rides, or of creasote, or of pyroligneous acid conjoined with creasote and spirits of turpen- tine, with or without this latter, are the most generally applicable. They may be used in the form of wash or lotion, or on the surface of any of the several kinds of poultices commonly pre- scribed. 76. b. In gangrene from animil poisons, the local treatment need not differ materially from that now advised. In this variety, as well as in others, different means have been recom- mended. The application of arsenic has been directed for phagedenic gangrene, by Fabricius Hildanus and Zinke ; the actual cautery, by Celsus, Michel, Loefler, Murray, and oth- ers ; powdered bark, with turpentine, by Knack- stedt ; these latter substances, conjoined with the hydrochlorate of ammonia, by Dussassoy ; the sesquioxide of iron, by Brandis ; charcoal, by Marcus, Beddoes, and Bornemann ; the pyroligneous acid by Simons ; and a strong mixture of camphor in thick mucilage, spread over the part, by Schneider. In this form of gangrene, more, perhaps, than in any other, it is important completely to exclude the external air from the diseased surface ; at the same time, the intentions with which external reme- dies are employed (y 75) should be strictly ob- served. Therefore, while the morbid secretions of the part should be prevented from accumu- lating, or be corrected by the antiseptics already mentioned, the access of air ought to be ex- cluded by means best calculated to fulfil this end, and to be also the vehicles of antiseptic and stimulating remedies. A thick mucilage may, perhaps, be as advantageously used in this way as any other substance. But this in- tention is important not only in a curative, but also in a prophylactic point of view. It is ob- served by nature in all external sores presenting a disposition to heal. When an eschar can be formed by any application, the end here kept in view may be accomplished by it. Indeed, the substances frequently resorted to in the present day, particularly the nitrate of silver, the actual cautery, and the stronger acids, as the nitric or hydrochloric, are beneficial by their opera- tion in this manner, as much as by the stimulus they impart to the diseased surface. 77. c. The hamorrhage that often takes place upon the separation of the sloughs in phagedenic or hospital gangrene may be arrested either by the means just mentioned, or by the application of the spirits of turpentine containing creasote, or of strong pyroligneous acid with the acetate of lead, or of a concentrated solution of the chlo- ride of lime, or of any of the strong metallic salts. 78. d. In cases of the bites of poisonous rep- tiles, or even of the inoculation of virulent or morbid matter, the application of cupping glass- es, or of other instruments by which the air may be exhausted over the seat of injury, was recommended by Celsus, and in modern times by Sir David Barry. The ancients, especially the Egyptians, resorted to suction for the re- moval of these and other poisons, when intro- duced by bites or wounds; and the practice is general even in the present day, in uncivilized countries ; the fact having been well known to them, that the individual administering this sort of aid will not himself be injured, if no abrasion exist on his tongue or lips. The com- mon procedure in these countries is immedi- ately to place a ligature above the part where the poison has been inserted, when this can possibly be done, and next to have recourse to suction for its removal. I have seen this prac- tice resorted to on two or three occasions with success. When, however, it has been too long GANGRENE—Local Treatment. 27 delayed, or cannot be adopted, ammonia, spirits of turpentine, and various stimulating sub- stances may be applied to the part, as advised in the article Poisons. If gangrene have taken place, the local remedies noticed above are the most appropriate. 79. iii. The Diet and Regimen in gangrene must necessarily be regulated according to the peculiarities of the case ; but, in general, a mild, spare, and digestible diet only should be prescribed. If the patient enjoy not a pure and dry air, he should, if possible, be removed to a situation possessing this advantage. His mind should be encouraged, and his confidence en- sured by the attention of his attendants and the bearing of his physician. [In treating the gangrene of old people, our remedies should be directed to renovate the nervous influence of the capillary vessels, es- pecially of the part affected, for it is doubtless owing to the loss of nervous energy in these vessels that they lose the power of preserving the vital properties of the blood ; and this fluid, consequently, becomes decomposed in the ves- sels. It is a mistake to suppose that this dis- ease always results from ossification of the ar- teries, for we meet with it, as Wedemeyer has remarked, where these vessels are not ossified ; nor does such a state of the arteries always produce gangrene ; the treatment, therefore, is to be based on a different pathology. M. Dupuytren supposes that gangrena senilis is of an inflammatory nature, and is best treated by antiphlogistic means and cold water; and that amputation is advantageous in this and certain other conditions of gangrene, in which its propriety has not been commonly admitted. In its treatment, it is necessary to bear in mind that gangrene, once commenced, is a cause of more inflammation, and, by consequence, of its own farther extension; and hence amputation is proper when mortification is spreading, when it is slow, and has occurred without any known cause (Josse). It is necessary, also, in treat- ing gangrene with success, to distinguish gan- grenous inflammation from gangrene, as point- ed out by Mr. Travers* The former is inflam- mation, of which the termination or event is gangrene ; and, of course, it must be treated, in its earliest stage, by antiphlogistics, both lo- cal and general; but in cases where gangrene depends upon strangulation, or arrested circu- lation from a change in the structure of parts, or to decomposition from heat, cold, or chem- ical agents, the inflammation is evidently the result of the gangrene, not its cause, and is a conservative process set up to circumscribe and throw off the gangrenous part. We here find the gangrenous part dry, shrunk, and mum- mied ; and where a conservative process is es- tablished, the line of demarcation is announced by the deposition of adhesive matter, which is followed by ulcerative action, beginning upon several points, and proceeding along this line until separation is effected, the construction of granulations out of the adhesive matter consti- tuting the third process, and thus advancing the final stage of repair, viz., the fabrication of the new surface. To facilitate this process, the health, of course, is to be maintained in its utmost vig- * [»'Au Inquiry on Constitutional Irritation," &c, by Dekj. Tbavebs. Loudon, 1835.] our, in order that the proper materials of repair may be furnished in sufficient quantity and of a healthy quality. And it is an important cir- cumstance in these cases that the health is often but little interrupted, so that the system is able to take and apply the support which the case calls for. In true gangrene, then, we have a limb, for example, dry, cold, pallid, shrunk, and insensible ; while in gangrenous inflamma- tion we have the same part swollen, moist, liv- id, vesicated, and acutely painful; the adhe- sive inflammation is wanting, and we are wise- ly directed by the best surgical writers not to amputate until a barrier is established ; going upon the sound principle that, if the system does not possess sufficient conservative power to destroy or check inflammation, it has not power to initiate a healing one, and, conse- quently, that the same mischief would fall upon the stump. The typhoid symptoms consequent on gangrenous inflammation—the livid and ca- daverous complexion, deficient alvine and uri- nary secretions, thirst, brown or black furred tongue, hiccough, cold, clammy skin, anxiety. and muttering delirium—point with unfailing accuracy to the proper remedies—ammonia, wine, camphor, opium, quinine. The distinc- tion above pointed out is an important one, as regards the treatment of this frequent and oft- en embarrassing affection. There are several distinct varieties of gan- grene, occurring in infants and young children, which occasionally come under notice, and require much judgment on the part of the practitioner. These are, gangrene of the gums and mouth, including the cheek, which rapidly spreads, and destroys the structure of the sur- rounding tissues ; this is sometimes called gan- grenopsis, or the erosive gangrene of the cheek , mortification of the external parts of generation in female infants and children (herpes, or vesicu- lar inflammation of the labia, not unfrequently terminates in this form of gangrene); gangrene of the skin, described by Billard under the name of gangrana neonatorum; and, lastly, the gangrene which occasionally follows erysipelas in infants. Of these, the cancrum oris, or gangrenopsis, occurs the most frequently in this country, and it sometimes has been known to prevail epi- demically in some of our public institutions for the reception of children/ and is generally con- nected with imperfect nourishment, want of cleanliness, and an impure atmosphere. It oc- curs, moreover, among children of lax and de- bilitated habits, and of a strongly-marked lym- phatic temperament. For the most part, it com- mences upon the centre of the internal surface of one of the cheeks, which becomes swollen, hard, dark-red, and shining ; at length it ulcer- ates ; and as the ulceration extends, a livid spot, surrounded by a red areola, makes its ap- pearance on the external surface, at the spot where the tumefaction is greatest, which as- * [Dr. Coates states that there was at one period, in the Children's Asylum of Philadelphia, among the 240 inmates, 70 affected with gangrene of the mouth. On dissection, the mesenteric glands, as well as those of the neck, were found enlarged and hardened ; and tubercles existed in the lungs in every instance. In nine cases reported by Dr. Jackson of Philadelphia, the disease occurred in the course of, or subsequent to, an attack of remittent or bilious fever. Ac- cording to our observation, the disease generally is prece- ded by gastro-intestinal irritation ; a fact also noticed bv Marshall Hall, Condie, and others.] 28 GA.SGRENE—Local Treatment—Bibliography and References. sumes a dark hue, and spreads, with greater or less rapidity, until the whole cheek is involved. in arresting gangrene of the mouth, it is impor- tant to remove the patient immediately into a pure and dry atmosphere ; observe strict clean- liness ; and allow such diet, of a nourishing Kind, as will prove least irritating to the digest- ive organs ; mercurial preparations are to be entirely withheld, as it is believed that they tend to develop the disease ; quinine may be cautiously given ; if local inflammation exists, leeches are to be applied ; and where there is tumefaction of the cheek, a blister over the tu- mour will prove beneficial; the gangrene is to be arrested by applying, twice a day, to the parts affected, a strong solution of sulphate of copper (jij. to f iv.), or a solution of sulphate of zinc (31. to §i. of water), or the nitrate of silver, either in pencil or solution. We have known the last-named agent to arrest this disease in several cases very promptly. Dr. B. H. Coates States (North Am. Med. and Surg. Journ., vol. ii.) that he treated 170 cases, within three months, in the Children's Asylum of Philadel- phia, very successfully, by using the following as a local application : % Sulphate of Copper, 31J.; Pulv. Cinchona, f ss.; Water, f iv. ; to be applied twice a day to the full extent of the ulcerations and excoriations. The cinchona serves to retain the sulphate longer in contact with the edges of the gums. Simple ulcerations and small gan- grenes, adds Dr. C, as well as troublesome ex- coriations, when not in the last stage, yielded promptly to this remedy, the good effect being generally visible from the first application. Dr. Parish recommends, in similar cases, the fol- lowing lotion : R Sulph. of Zinc, ji., Water, i.— T. Kirkland, Thoughts on Amputation, and an Essay on Opium in Mortifications, 8vo. Lond., 1779.—/. Harrison, The remarkable Effects of Fixed Airin Mortifications, 8vo. Lond.. 1785.—Pouteau, CEuvres Posthumes, t. iii.. 1783.—L. Gillespie, Lond. Med. Journal, vol. vi., 1785.—Murray (Adolph.), Diss, do Usu Inustionum vario et praecipue in Gangranft Metastatica. Upsal.. 1767.—Doering, vol. i., p. 217.— .Mtza, in Act. Reg. Soc. Med. Hafn.. vol. i.— Hagendorn, Cent, iii., obs. 38.— Le Cordier, in Journal de MedeCine, t. ix., p. 17.—l)arlue, in Journal de Medecine, t. x., p. 209.— C. White, Observ. on Gangrenes or Mortifications, 8vo, Warrington, 1790.—I GASTROENTERIC DISEASE. 29 /. Hunter, A Treatise on the Blood, Inflammation, &c, 4to. Lund., 1794.— Wollaslon, in Philos. Transact., vol. Iii., p. 2. —Rossignolly, in Juurnal de Medecine, t. ix., p. 307.—Ha- ger, Diss, on Gangrene and Mortification. Philad., 1797.— Hufeland, Journal der Pr. Arzneyk, b. ii., p. 609.—C. Him- ly, Abhandlung ueber den Brand der Weichen und Harten Theile, 8vc. Goett., 1799.—K. G. Neumann, Abhandlung vom Brande und Hoilmethode desselben, 8vo. Wien., 1801. —Brechet, Considerations sur l'Usage du Charbon en Mede- cine, Journal General de Medecine, t. xviii., p. 364.—More- lot, in Journal General de Med., t. xx., p. 290-293.—Heck- er, Annalen der Gesammten Medicin., 1810, Jun., p. 510. —Hufeland und Himly, Journal der Pract. Heilk., 1812. Nov., p. 115.—Vogt, Pr. de Amborum Pedum Gangraena in Dextro Sanatfi, in Sinistra Lethali. Viteb., 1803. — C. White, Obs. on Gangr. and Mortifications, posed to exist, is actually superinduced by the means erroneously resorted to for its removal GASTRO-ENTERIC DISEASE—Pathology. 33 M. Broussais has insisted upon inflammations of the liver being always consecutive of gastro- enteric inflammation. This, however, is one of the several generalizations at which he has arrived from insufficient data. But until he wrote, the fact that irritation of the digestive canal, allowed long to exist, or to go on to in- flammatory action, frequently induces chronic hepatitis, was entirely overlooked. There can be no doubt that prolonged and frequently re- peated over-excitement of the digestive canal by a too rich, stimulating, or full diet, or by spirituous or fermented liquors, is often follow- ed by hepatic disease; but, as shown in the article Liver, other causes, besides gastro-en- teritis, are concerned in producing it. One of the most common circumstances in the produc- tion or exasperation of intestinal irritation, and of the ultimate supervention of chronic hepa- titis, is the improper or too frequent use of acrid purgatives: a practice to which I have traced a number of the cases of hepatic dis- orders wbich I have seen in a warm climate, and more recently in this country, particularly among persons who have returned from the East Indies, or from other places within the tropics. 13. The occurrence of diseases of the liver, and even of abscess of it, consecutively upon chronic diarrhoea and dysentery, has long at- tracted the attention of most practitioners in warm climates. In many of such cases, al- though there may have been reason to suppose that the hepatic disorder preceded, or even caused the intestinal affection, there can be no doubt that the persistence of this latter, or the exasperation of it by a purgative treatment, has rendered the former more acute and manifest. Some difference of opinion exists as to the mode in which the gastro-enteric disorder is propagated to the biliary organs. Some sup- pose that the excitement is sympathetically extended to them, this extension being favour- ed by the associated functions of these differ- ent organs. Others believe that the inflamma- tion has spread from the mucous surface of the duodenum to that of the biliary ducts. Instan- ces have been adduced by Andral, Ribes, Bouillaud, and Reynaud, which favour the in- ference that inflammation commences in the radicles of the mesenteric veins, and extends along the vena porta, and its ramifications in the liver. This, however, must be a circum- stance only of occasional or rare occurrence. I have, however, long since supposed that the more acute attacks of inflammation of the sub- stance of the liver, and the purulent collections frequently formed in it, in the course of chron- ic dysentery, have been superinduced in this manner. Upon the whole, it may be inferred, that in complications of gastro-enteric with bil- iary disorder, either lesion may have been pri- mary ; but that in this climate, especially, the gastro-enteric more frequently precedes than follows the hepatic affection. In warm cli- mates the converse of this probably obtains, although not to the extent very generally be- lieved by many practitioners who have written on intertropical diseases. 14. b. That disease of the mesenteric glands is generally induced by the frequent recurrence or persistence of gastro-enteric irritation and inflammation, often connected, however, with " 5 various other elements of disorder, is suffi- ciently evident, and now very generally admit- ted. And yet I have seen, especially at an early period of my practice, this malady treated by purgatives, sometimes of a very acrid na- ture. The enlargement and obstruction of these glands depending chiefly on the affection of the digestive mucous surface, can be reme- died only by the previous removal of this latter affection, and by the prevention of its recur- rence. When this end is obtained by local de- pletions, by refrigerants conjoined with the al- kaline subcarbonates, ipecacuanha, and demul- cents, and by suitable diet and regimen, the consecutive disease of the glands often gradu- ally disappears. 15. VI. The Connexion of Gastro-enteric In- flammation with Diseases of the Skin is much more general than practitioners in this country suppose. It is chiefly owing to the irritation of the digestive mucous surface in various grades of severity that the cutaneous affection resists so long the treatment prescribed for its removal. I have repeatedly seen cases of eczema, and of other obstinate diseases of the skin, complicated with the slighter and more chronic grades of gastro-enteritis, the latter being even so prominent as to be indicated by epigastric pain and tenderness; yet arsenical, or other irritating medicines, were exhibited in no small quantities ; and, although they were evidently exasperating both the internal and external affections, they were continued with a perfect belief of their applicability. Upon the- adoption, in these cases, of general or local depletions, of refrigerant medicines, of warm and medicated baths, and of a light and appro- priate diet, all disorder has soon after disap- peared. The chief reasons of diseases- of the skin proving so obstinate are, 1st. This form of complication ; 2d. The inflammatory diathe- sis and vascular plethora characterizing them -r 3d. The neglect of these pathological associa- tions, and the adoption, in consequence, of inap- propriate means of cure ; 4th. Inattention to diet and regimen, particularly as respects the use of animal food and stimulating beverages and articles of diet; and 5th. An insufficient observation of the states of assimilation and excretion, with the view of perfecting the for- mer and of promoting the latter. 16. VII. Chronic Gastro-enteritis is often asso- ciated with Affections of the Genit.o-urinary Or- gans, and with Gout.—We sometimes observe leucorrhcea and other uterine disorders con- nected with gastric irritation ; the former most frequently being induced, or favoured in its oc- currence by the latter. Difficult or scanty menstruation is occasionally traced to the same cause. In these cases, the means calculated to relieve the disorder of the digestive mucous surface are generally most efficacious for re- moving the sympathetic affection. A similar association of the disorders of the digestive and urinary passages is sometimes also observed; but it is unnecessary to do more than to refer to it. How far gastro-enteric irritation may influence the states of urinary excretion has never been so fully illustrated as is to be de- sired. What we know of the subject is derived from the researches of Dr. Prout ; and it is to be hoped that this scientific physician will pro- i ceed in his investigations into it. There can. 34 GLANDERS—Description or. be no doubt that a state of chronic irritation or of inflammatory erythism of the digestive mu- cous surface, will so impede the functions of digestion and assimilation as to cause a super- abundance of materials in the blood, calculated to excite or to disorder the actions of the kid- neys, and requiring to be eliminated from the circulation. When this disorder of the gastro- enteric surface is attended, as it not infre- quently is, with a craving or morbidly excited appetite, food is taken in larger quantity than it can be digested ; and much imperfectly form- ed chyle is carried into the blood, where it ex- cites disorder of the liver, of the kidneys, and of the skin, in the course of the excretion of the unassimilated matters by these organs. To this source may be traced, in many instances, not only the morbid conditions of the urine, and of the kidneys themselves, but also the produc- tion of an attack of gout in a regular or irregu- lar form. 17. The therapeutical indications, and even the means of cure, for these various gastro-enteric complications, may be readily inferred from what has been stated above. More precise in- formation will, however, be obtained as to these topics, and as to the causes of the gastro-enteric disorder, by referring to the articles Gout, In- digestion, Intestines, Stomach, &c. Bibliog. and Refer.— Roederer et Wagler, De Morbo Mucoso, Svo. Goett., 1768.— W. Henning, Beschreibung der Kennzeichen und Cur der Enzundung des Magens unci der Gedarme, 8vo. Kofenh., 1781.—A. Pujol, Essais sur les Inflammations Chroniques des Visceres (CEuv.de Med., t. i.), Svo. Castres., 1802.—A. Petit et E. R. A. Serres, Traite de la Fievre Entero-Mesenterique, 8vo. Par., 1803. —P. A. Prost, La Medecine Eclairee, &c, 2 vols., 8vo. Par., 1803.—Chauvin, Considerations sur la Gastro-Ente- rite, 4to. Montp., 1821.—Leclerq, De la Gastro-Enterite des Enfans, 4to. Par., 1821.—Rayer, Diet, de Med. (art. Gastro-Enterite), t. x. Par., 1824.—C. Billard, De la Mem- brane Muqueuse Gastro-Intestinale dans 1'Etat Iiiflamma- toire, 8vo. Par., 1825.—F. J. V. Broussais, Exanien des les Doctrines Medicales, &c. Par., 1821,2 vols. ; 1826, 3 vols.; Hist, des Phlegmasies ou Inflam. Chroniques, &c, 3t., 8vo. Paris, 1826, 4to edit.; Traite de Physiol, applique a la Pathologie, 2 t., Svo. Paris, 1824 ; Comment, des Propo- sitions de Pathologie, Ac, 2 t., 8vo. Paris, 1829 ; Lec- tures, translated by Gully, in Med. and Surg. Journ., vol. viii., passim.—Scoutetten, in Journ. des Progres des Scien- ces Medicales, t. viii., p. 252.—P. C. A. Louis, Mem. ou Recherches Anatomico-Pathologiques sur Plusieurs Mala- dies, &c, 8vo. Paris, 1826 ; et Recherches Anat. Path. sur la Phthisie, 8vo. Pans, 1825.—Andral, Clinique Med., 5 tomes. Paris, 1832, 2d edit., passim.—W. Stokes, art. Gastro-Enteritis, in Cyclop, of Pract. Medicine, vol. ii., p, 334.—Roche, Diet, de Med. Prat. (arts. Gastrite and Gas- tro-Enterite), t. ix. Paris, 1833. GLANDERS. Classif.—III. Class, III. Order (Author: see Classif. in Preface). 1. Defin.—Vascular injection, and chancry sores of the membrane of the nose, frontal sinus, and parts adjoining, with a profuse offensive dis- charge, and pustular eruptions, or tubercular and gangrenous ulcers in various parts, preceded by constitutional disorder, attended by fever of a low or malignant character, and produced by contagion. 2. Glanders until lately was considered ex- clusively to belong to the horse, the ass, and the mule [also to dogs, sheep, and goats]. Within this few years several cases have oc- curred, showing that it may be communicated to man, in either the acute or chronic form. About twelve years ago, in the course of a dis- cussion at the Medico-Chirurgical Society, I stated that the fact of the disease having been thus communicated had been proved by cases *hat had occurred in Germany. The cases to which I then alluded were published in Rust's Magazine for 1821. Since then, cases have been observed in this country, and published by Mr. Travers, Mr. Brown, and Dr. Elliotson. It is to this last gentleman, however, that we are most indebted for a full elucidation of the subject, by his able researches. The frequency of the occurrence of the disease in the human subject justifies the notice that will be taken of it in this work.* 3. Andr and chronic glanders are contagious among the animals just mentioned; but, from the facts adduced by Mr. Coleman, Dr. Ash- burner, and Dr. Elliotson, it evidently ap- pears that the disease may be generated anew when horses are shut up in a confined space for a long time, as on board transports. The characteristic symptoms of the disease in its acute form in the horse are, intense inflamma- tion of the pituitary membrane, attended by erosions which soon pass into chancre-like sores ; swelling of the lips and nose ; rapid ex- tension of the ulceration, giving rise to a puru- lent and disagreeable discharge, which often passes to a purplish, or bloody, and horribly foe- tid sanies ; subsequently, gangrene of the nasal membrane, with increased discharge, some- times with slight haemorrhage; swelling and pain of the sublingual glands ; inflammation of the conjunctiva and nasal eyelid, quickly pass- ing into a livid and swollen state, with an of- fensive sanious discharge ; and fever of a pu- tro-adynamic or malignant character. As the local changes extend to the adjoining parts, respiration becomes laborious, and the superfi- cial vessels congested, the animal dying in a few days, or after a longer or shorter interval. If the disease is protracted, the symptoms sometimes relax, but the state of the pituitary membrane and the character of the discharge show that it has degenerated into a chronic form. Pustules may also appear in the prog- ress of glanders, with gangrene of the external parts of the face, and tumours with swelling of the extremities, the disease being thus as- sociated with farcy, which is a modification of it. 4. The farcy glanders generally appear in the form of small tumours about the legs, lips, face, neck, or other parts of the body; these tumours vary in size, and in the rapidity of their progress to ulceration. They sometimes cre- ate little inconvenience, particularly in a chron- ic state; but at other times they are large, painful, numerous, and rapid in their course. They are at first hard ; soon become soft, burst, and degenerate into foul ulcers, with abrupt edges, and of a pale, glossy appearance. Lines of communication are generally observed be- tween these tumours or ulcers, particularly when seated on the insides of the limbs: these lines are inflamed and enlarged absorbents. 5. I. Description of Glanders in the Hu- man Subject. — Dr. Elliotson remarks that * [This disease has attracted much attention during the last ten years (see " Bibliography"), and in that time it has been abundantly proved that the acute form at least is contagious, and may be communicated by the nasal se- cretion,^ the expired air, the blood, and the tissues of the dead body. It may also be conveyed from one human sub- ject to another (Gaz. Medicale, 1844). The period of in- cubation of the poison varies from two to eight days; the disease, when acute, may prove speedily fatal, or may run 30 days ; the chronic, however, rarely lasts longer than the I latter period ] GLANDERS—Forms op. 35 glanders may appear in the human subject in different forms. 1st. In that of simple acute glan- ders ; the disease attacking the nasal cavities and adjoining parts. 2d. In that of acute farcy glanders ; the malady appearing in various parts in the form of small tumours, giving rise to foul ulcers, suppuration, &c. 3d. These varieties may exist separately, or they may be both pro- duced at the same time, or the one may pre- cede the other. 4th. Each of them may also occur in a chronic form, and in this form, also, may exist separately or be conjoined. That the acute true glanders and the farcy glanders are the same disease is proved by the fact that the matter deposited in the tumours character- izing the latter, or that coming from the nos- trils in the former, gives rise to either of these varieties, or to them both conjoined ; or, in oth- er words, that simple acute glanders may pro- ceed from the matter of farcy or from its own discharge, and that farcy glanders may arise from the discharge from the nostrils in simple acute glanders. 6. i. Simple Acute Glanders appear to com- mence with rigours, headache, irritability of stomach, depression of spirits, prostration of strength, stiffness and severe constant pain of the joints, aggravated on motion, and great thirst. The patient, moreover, complains of much heat about the nasal organ and windpipe, accompanied with a copious viscid discharge. The nose and surrounding parts become swol- len, hot, excoriated, and of a bright red or livid colour ; one or both eyes are inflamed, or com- pletely closed ; a profuse tenacious mucus, at first of a deep yellow, but afterward of a bloody or dark sanious appearance, exudes from one or both nostrils, sometimes also from the eyes ; and several hard phlyzaceous pustules appear on the nose and adjacent parts, and on the neck, trunk, arms, thighs, and legs. The tem- perature of the skin is increased; the pulse is remarkably frequent, soft, and weak, or undu- lating; the respiration rapid, weak, and shal- low ; the tongue dry, rough, and brownish-red ; thirst is unquenchable ; the stools are watery, or slimy and offensive ; the voice is weak, and the mind incoherent or wandering. Copious offensive sweats, a livid or gangrened state of the nose or of adjoining parts, delirium, tre- mours, and restlessness, are also observed ; fol- lowed by sinking of all the vital powers, disap- pearance of the pulse, and death within a very few days ; the fcetor from the discharges, and from the whole body, towards the close of the disease, being insupportable. 7. Upon inspection post-mortem, the morbid ap- pearances, especially those which are external, are greater on one side of the body than on the other. The lungs are engorged with dark fluid blood ; the bronchi are livid, congested, and partially filled with a dark, frothy mucus ; the nostrils and frontal sinuses contain a glutinous matter, of a brownish colour, and the lining membrane is studded with ulcerated white tu- bercles or granules ; irregular ulcers, or white circular chancres, sometimes also exist in the upper parts of the air-passages; purulent de- posites are occasionally found in some of the internal viscera; and the mucous surface of the digestive canal is softened and discolour- ed at various points. White tubercular forma- tions, resembling those found in the membrane of the nose, sometimes also exist in the mu- cous membrane of the large bowels. 8. ii. Acute Farcy Glanders seems to com- mence with severe pain in the joints and limbs, and with the other symptoms attending the in- vasion of the preceding variety. Small tu- mours arise in different parts of the body, but are more numerous on one side than on the other, and have a glossy red appearance, which soon changes to a dark brown. They also af- fect the head, or even the face, and chiefly on one side. They are painful, soon crack on the surface, and exude a thin acrid sanies: they vary in size, and are generally accompanied by phlyzaceous pustules in different parts of the body. Perspiration is free, copious, and fcetid ; and the stools are watery, offensive, or other- wise morbid. The fauces are injected, and of a purplish hue ; thirst is great; the tongue foul, loaded, and dark-coloured ; the pulse quick, and easily compressed, afterward small, and scarcely perceptible ; and the other symptoms attending a fatal termination soon afterward appear, as in the preceding form. On inspec- tion after death, the tumours are found deeply seated. On removing the gangrenous integu- ment covering them, a layer of brown glutin- ous matter is seen covering small white tuber- cles, having the same appearance as those found in the frontal sinuses and nasal cavities in acute simple glanders. These tubercles on the forehead or scalp are generally connected with the pericranium ; but, on the limbs, with the fascia?. In some cases, on dividing the lar- ger livid or gangrenous tumours down to the bone, the muscles appear decomposed, are of a dark colour, exhale a peculiar fcetid odour, and contain specks of purulent matter, as it were infiltrated through their substance. Under- neath these muscles, clusters of circular gray tubercles are also found, firmly attached to the periosteum, and resembling those that are more superficial, as in the pericranium, &c. The muscles generally, even those remote from the tumours, are blanched, flabby, or softened, and the cellular tissue is infiltrated with a yellow- ish serum. The Schneiderian membrane, front- al sinuses, and parts adjoining, are sometimes thickened or studded with white tubercles. The blood is dark, fluid, and decomposed ; and the heart flabby and pale. 9. When acute farcy is conjoined with acute glanders, the affection of the nares and respira- tory organs, the phlyzaceous pustules around the nose and mouth, and the consequent fcetid, sanious discharge and disorganization, are as- sociated with the foregoing phenomena; but the constitutional symptoms are not thereby otherwise changed than in being aggravated, or rendered more malignant or more rapid in their progress to dissolution. In such cases, the morbid appearances of the nares, fauces, and respiratory surfaces attending the acute glanders are superadded to those characteri- zing acute farcy. 10. iii. The Chronic Forms of Glanders.—Sim- ple chronic glanders is confined chiefly to one nostril, and is characterized by a glutinous and very offensive discharge, the fcetor being pecu- liar, and remarkably disagreeable. There are itching, a constant desire to blow the nose, and a sensation of stuffing. In the slightest state of the disease, these may be the principal symp- 36 GLANDERS—Treatment. toms ; but* in an advanced stage, or in severer cases, there are pain between the eyes and down the nose, suffusion of the eyes, and ul- ceration of the Schneiderian membrane ; the discharge being copious, puriform, or sanious. These symptoms are usually preceded by shiv- erings, giddiness, and by weakness and pains of the limbs ; and are followed by more or less constitutional disturbance. As the disease pro- ceeds, purulent collections form in different parts. There are, moreover, loss of appetite, nausea, swimming or pains of the head, occa- sionally wanderings of the mind, pains in the back and limbs, thick, discoloured, or fcetid urine, and slimy, or otherwise morbid evacua- tions. From this state the patient may slowly recover, after an indefinite period, or may sink gradually, from prostration of all the vital pow- ers, with appearances of contamination of the circulating and secreted fluids. 11. Chronic farcy glanders are generally pre- ceded and accompanied by chills or rigours, and aching pains through the body and limbs, resem- bling rheumatism. Tumours gradually form about the face, trunk, and limbs ; these break, and give rise to an unhealthy discharge ; and are attended or followed by disease of the ab- sorbents and glands, or by purulent collections in the joints, or in various parts of the body. The disease may commence in this manner, and thus terminate; or it may pass into the state of chronic glanders ; or, in other words, the affection of the respiratory passages char- acterizing simple glanders may be superadded; or it may commence in this latter form, and be followed by the symptoms more especially marking the chronic form of farcy. In either case, the matter produces, as shown by the ex- periments of Mr. Coleman and others, acute glanders or farcy indifferently. 12. iv. The Nature of this Disease may be in- ferred from the history here given of it. It is evidently the result of a specific morbid matter, contaminating the surfaces and parts to which it is applied, affecting the organic functions, and giving rise to the changes characteristic of it. The state of the blood has not been suf- ficiently attended to in the history of the cases which have been put upon record. In several of those that occurred in Germany, the blood taken at an early period of the disease appear- ed to be cupped or buffed; but it afterward seemed deficient as to crasis, or partially dis- solved, and very dark. In the variety of farcy, the absorbents, as well as the glands, appear to be much affected, probably owing to the pas- sage of morbid matter along them ; but there is much yet to learn as to the history of the disease and the lesions which it occasions, and still more as to its treatment. 13. v. The Prognosis of the acute varieties of glanders is extremely unfavourable, all the ca- ses observed in the human subject having termi- nated fatally.* The chronic states of the malady seem not much less dangerous. Two or three, however, of those which have been recorded appear to have recovered. In one of those mentioned by Mr. Travers, the patient was cured by means one of the principal effects of which was to produce frequent vomiting. Dr. Elliotson remarks, in his last paper on this * [Since this was written several cases have recovered under the use of creasote and turpentine.] disease, that its occurrence in the human sub- ject is by no means of extreme rarity; and that, since the publication of his former paper, upward of a dozen cases had been mentioned to him by medical men. 14. II. Treatment.—Our knowledge of the treatment of this malady has not heen much advanced by the experience we have hitherto had of it in the human subject. The prophylac- tic means are, however, made sufficiently evi- dent by the recognition of its cause. There can be no doubt that it is communicated to man only by contact of the morbid matter proceed- ing from another person or animal suffering from it; and it would appear that the infection is most certainly produced by this matter being brought in contact with an abraded or punctu- red surface. Whether or not it is capable of producing the disease by being applied to the unabraded mucous surface, or by merely con- taminating the air breathed by the unaffected, is certainly not proved as respects the human subject, although there are a few facts which seem to favour the affirmative conclusion. As regards, however, the horse and ass, there can be no doubt of the frequency of this mode of infection ; and, indeed, of the possibility of the disease being generated de novo, when circum- stances such as those already alluded to ($ 3) contaminate the atmosphere in which a large number of those animals are confined.* 15. The method of cure is not so evident as the means of prevention. It may, nevertheless, be directed with the following intentions: 1st. To arrest the progress or change the character of the local affection ; 2d. To moderate or modify the constitutional disturbance accom- panying it; and, 3d. To counteract the contam- ination of the fluids and soft solids taking place in its progress, and to support the powers of life. These indications require means for their fulfilment possessed of energy proportionate to the violence of the disease ; and while the lo- cal symptoms are attacked, the constitutional powers should be assisted in opposing their ex- tension. With these views, the more volatile stimulating antiseptics, or warm aqueous va- pour conveying their fumes, may be inhaled, or diffused in the patient's apartment. Solutions of the chlorides may be sprinkled around; or pyroligneous acid, with creasote and camphor, or spirits of turpentine, may be scattered over the bedclothes, or put into an inhaler with warm water, and the fumes inspired. Any of the ter- ebinthinates may be similarly used ; and solu- tions of either of these, or of the chlorides, may be frequently injected, or employed as gargles. The chlorate of potash, or Labarraque's anti- septic solution, may also be tried internally; and stimulating diaphoretics prescribed early in * [The results of observations in Paris show that the glanders is not a highly contagious disease ; for of one hun- dred horses exposed to the contagion, it is stated that only seven or eight suffered ; and, on one occasion, when more than six hundred glandered horses were collected together at Alfiirt, not one of the persons who had charge of them took the disease. This affection is so frequent in Ireland, that Dr. Graves is of opinion that the Legislature is called on to imitate the example of the Prussian government in placing glandered horses under the surveillance of the po- lice (Clinical Led., Am. Ed., by Dr. Gebhabd, p. 814, 1842). We have heard of but few cases of the disease ia the human subject in this country, although it is frequent- ly met with in horses ; and as little precaution against it is used, we infer that the susceptibility to it is not as great as has been represented.] GOUT. 37 the disease. The vapour bath, with the fumes of camphor diffused in it; the warm bath, con- taining a sulphuret, or consisting of water in which aromatic and stimulating herbs are in- fused ; the nitro-hydrochloric acid, or chlorine baths, &c, are severally deserving of trial. Terebinthinate embrocations, as warm as they can be endured, may also be applied externally; or turpentine may be given internally in small and often-repeated doses, with aromatics, &c. The various means detailed in the article Fe- ver (y 559, et seq), with reference to the treat- ment of the typhoid varieties, may likewise be resorted to. 16. Dr. Elliotson mentions (Med. Gazette, vol. vii., p. 655) that the veterinary surgeon of the 13th light dragoons treated this disease in the horse by putting a quantity of scalded bran, mixed with Venice turpentine, into a horse- hair bag, and tying it over the horse's head ; the whole body of the animal being wrapped at the same time in a large blanket wrung out of boil- ing water, and covered with several horse- cloths. This treatment procured a profuse sweat, and a free discharge from the frontal sinuses and nostrils, and promoted the healing of the ulcerations. Dr. Elliotson also states, in his last paper on this disease, that the sedu- lous injection of a solution of creasote up the nostrils removed the whole of the symptoms, in a case of chronic glanders in the human subject, after a very few weeks. Mr. Storry (Veteri- narian, vol. vii., p. 145) adduces cases in which fumigation with carbonic acid gas appeared beneficial in glanders occurring in the horse; but other means, as calomel, aloes, &c, were also employed. [In one instance, Mr. Travers succeeded in effecting a cure by the frequent administration of emetics. Raver recommends the imme- diate excision of the swollen glands in the ear- ly stages of the disease ; and also mercurial frictions. He also thinks highly of the acetate of ammonia in large doses, and repeated pur- gings. As to topical treatment, he advises the free incision and subsequent cauterization of the pustules and abscesses, while the patient's strength is supported by tonic drinks, wine, &c. The oil of turpentine has recently been given with success in a case of glanders in the horse (Lond. Lancet, No. 390, p. 689).] 17. In the chronic, as well as in the acute states of the malady, tonics or stimulants con- joined with purgatives, particularly cinchona, or the sulphate of quinine, capsicum, and cam- phor, with aloes, &c. ; antiseptics, as the chlo- rides, hydrochloric acid, or chloric aether, cre- asote, and pyroligneous acid; warm alterative diaphoretics, especially guaiacum, mezereon, senega, sassafras, sarsaparilla, variously com- bined ; the terebinthinates, balsams, &c, and fumigating or medicated warm baths, may sev- erally he prescribed and varied, appropriately to the characters of the case. The excessive thirst always attending the disease will be most beneficially quenched by a liberal use of soda water, spruce or ginger beer. Seltzer water, &c, which may be rendered still more cooling by the addition of small quantities of nitre, or of the carbonates of the alkalies ; or they may be made the vehicles of several internal medi- cines. Bibliog. and Refer.—Rust's Magazin fiir die Ge- sammte Heilkunde, 8vo, 1821 and 1824 ; and Journ. der Prakt. Heilk., March. 1822. -B. Travers, Inquiry con- cerning Constitutional Irritation, 8vo, p. 397. Lond., UUi, 2d edit.—/!. Brown, Fatal Case of Acute Glanders in the Human Subject, Lond. Med. Gazette, vol. iv., p. 134 -H. S. Roots, Case treated by, in Iliid., vol in., p. 6™-J. El- liotson, Qn the Glanders in the Human Subject, Med. Chir. Trans., vol. xvi., part i., p. 171 ; vol. xviu., part >•> P;/"l (with a coloured plate); vol. xix.. p. 237 ; in Lond. Med. Gazette, vol. vii., p. 300, 655 ; in Renshaw's Med. and Surg. Journ., vol. vii., p. 606; and in Lancet, No. 61b, p. 398.— Wolff, Cases of Glanders in the Human Subject; and M. Vogeli, Cases of Farcy, Lancet, No. 605, p. 2, 3.—M. Vo- geli. Farcy in the Human Subject, Veterinarian, vol. vm., p. 214.—Alexander, in Hufeland u. Ossann, Journ., &c, b. ii., 1835.—Rayer, On Cutaneous Diseases. English edi- tion, p. 1202.—The volumes of the Veterinarian contain several papers on this disease. I can recommend this peri- odical to the notice of the reader, on account of the excel- lant communications in it upon comparative pathology and therapeutics. Many of these communications reflect much light upon practical medicine generally. It is to be hoped that the able and scientific conductor will continue his very useful researches into these subjects, and that the growing spirit of investigation in this branch of the profession will advance still farther, and receive due encouragement and consideration. [Case of Glanders, Med. Chir. Review, vol. xxvi., 1837, p. 500, from Medicinisch Jahrbucher.—Brown, Case of Glan- ders, Ibid., July, 1837, p. 246, from Dublin Jour., May, 1837.—James Johnston, Case of Glanders in the Human Subject, Ibid., Oct., 1837, p. 359. from Provincial Trans — Opinions on Contagion of Glanders, London Lancet, Aug. 5th, 1837, and Med. Chir. Rev., Oct., 1637, p. 500.—Dis- cussion at the French Academy on the Nature and Treat- ment of Glanders in Man, Ibid., Oct., 1837, p. 518.—Cases of Glanders in Man, Ibid., July, 1838, from Medicinische Zeitung, Mai, 1837.—Andral, On Glanders in Human Sub- ject, Ibid., July, 1839, p. 233, from Memomires de l'Acade- mie.—MM. Norrat and Bouley, Report on the Work of De- ville on Glanders, in Ibid., Ap.. 1840, p. 543, from Revue Medicale.—/. B. Tytler, Cases of Glanders in Man, Med. Chir. Rev., July, 1841, p. 279, from Ed. Monthly Jour., June, 1841.—A.Graham, Ibid., p. 280.—Delaharpe, Cases of Glanders, with Remarks, in Med. Chir. Rev., Jan.. 1842, p. 188, from Revue Medicale.—M. Berard, On Transmis- sion of Glanders from one Human Subject to another, Ibid., Ap., 1842. p. 532.—H. M. Hughes, Cases of Glanders in the Human Subject, Med. Chir. Rev., July, 1843, p. 233.—Af. Renaut. On Transmission of Glanders by the Blood, Ibid., Oct., 1843, p. 523.— Youatt and Percival, The Veterinari- an, or Monthly Journal of Veterinary Science, Lond., 1844. —John Field, Posthumous Extracts from his Veterinary Records, Lond., Svo. p. 236, 1844.—Review of the above Works, in Med. Chir. Rev. for Jan., 1844.—MM. Rayer and Breschet, Review of their Work on Glanders, in Med. Chir. Rev. for July, 1840, and in Brit, and For. Med. Rev. for July, 1838 ; also, Gaz. Medicale, 1840.—It seems that, from 1837 to 1840, no fewer than 27 persons have died in Paris of the Glanders. See Med. Chir. Rev. for Oct., 1844.— Robley Dunglison, in Cyclop, of Pract. Medicine. Philad., 1845, art. Glanders. Dr. D. treats of the disease under the name of " Equinia Glanduloca."—London Lancet, June 20th, 1833.] GLOSSITIS. See Tongue — Inflammation of. GOUT. — Syn. ApOpirtc (und rov apdpov) ; ap- OptrtKn vovooc, Hippocrates, Aretaeus. Ar- thritis, Auct. var. Uodaypn, Hippoc. et Aret. Uofiaypa (ruv noduv aypa, Lucian). Podagra, Auct. var. TloftarXyia, Gr. Morbus Articula- ris, Pliny. Chiragra ; Arthritis Podagra; Morbus Dominorum ; Gutta, Radulphus, Bar- tholin, &c. Febris Podagrica, Vogel. Poda- gra Arthritis, Parr. Arthrodynia podagrica, Swediaur. Cauma podagricum, Young. Ar- throsia podagra, Good. Goutte Arthrile, Fr. Gliedersucht, gichtschmerzen, Fussgicht, Germ. Gotta, Ital. Gota, Span. Classif. — 1. Class, Febrile Diseases ; 2. Order, Inflammations (Cullen). 3 Class, Sanguineous Diseases ; 2. Order, Inflam- mations (Good). III. Class, IV. Order (Author in Preface). 1. Defin.—Constitutional disorder, giving rise to a specific form of inflammation; often favoured by original or hereditary constitution ; appearing after puberty, chiefly in the male sex; returning after intervals ; generally preceded by, or alterna- 38 GOUT—Acute—Histort ting with, disorder of the digestive or other inter- nal organs ; and characterized by affection of the first joint of the great toe, by nocturnal exacerba- tions and morning remissions, and by vascular plethora ; various joints or parts becoming affected after repeated attacks, without passing into sup- puration. 2. I. Gout is one of the diseases, the nature and treatment of which were best known to the ancients. In modern times, however, the mor- bid relations and associations of the disease, and its various modifications have been more fully elucidated, and its treatment assigned, ac- cordingly, with greater precision. But attempts at distinguishing its various manifestations, lo- cally and constitutionally, and with relation to the numerous disorders arising in the gouty di- athesis, have induced modern writers to make so many divisions of it, and to arrange its forms and states so differently, as to render its study somewhat perplexing to the inexperienced. This is one of the greatest objections that can be urged to the works of Musgrave, Guilbert, and some others. The arrangements adopted by some of the best writers on the disease are, however, very similar ; and I will not mate- rially depart from them. Those of Cullen and Good nearly agree, and that of Sir C. Scuda- more and of Dr. Mackintosh is quite the same. Differing, therefore, but little from these wri- ters, I shall consider, 1st. Acute gout; 2d. Chronic gout; and 3d. Irregular gout. The forms described by authors under the appella- tions of regular, acute, inflammatory, chronic, ir- regular, nervous, atonic, lurking atonic, primary asthenic, primary fixed, anomalous, wandering, in- ternal, visceral, retrocedent, misplaced, latent, masked, emphysematous, flatulent, disguised, aber- rant, &c, will be appropriately considered un- der one or other of the above heads. 3. i. History of Acute Gout. — A. Of the Symptoms premonitory of the Paroxysm.—Al- though the gouty paroxysm may attack sudden- ly a person apparently in good health, especial- ly on the first occasion of its appearance, it is more frequently preceded by symptoms of dis- order referrible chiefly to the digestive organs. I believe that if the cases in which it is said to have appeared suddenly were investigated, it would be ascertained that more or less disor- der had existed for some days before the seiz- ure, although not so as to have excited any concern in the mind of the patient. The most common symptoms of premonition are, flatu- lence, oppression after a meal, irregular appe- tite ; heartburn, with acidity of stomach, some- times with acid or acrid eructations ; costive- ness, irregularity, or, more rarely, an irritable state of the bowels ; scanty, deep-coloured urine, becoming turbid or thick on cooling, or sometimes copious or pale urine; a sense of soreness, or occasionally of coldness, at the epigastric region ; itching or irritation of the skin ; drowsiness, or frequent yawning, rest- less or unrefreshing sleep, more rarely night- mare ; general lassitude and depression of spir- its. In some persons, the symptoms of gastro- intestinal irritation are still more manifest, the tongue being loaded, red at its point and edges, the epigastrium tender, and the stomach op- pressed after a meal. In many cases, increase of corpulency ; scanty, thick urine ; drowsi- ness, especially after eating, and a sense of general fulness and oppression, have preceded the paroxysm for a longer or a shorter time. accompanied by several of the preceding symp- toms. The appetite is frequently craving ; and when indulged, is often followed by nausea, or vomiting of acrid matter, or by heartburn, flat- ulency, acrid eructations, &c. The premoni- tory symptoms vary in different persons, and depend much upon idiosyncrasy. Dr. Mackin- tosh justly remarks that persons subject to gout are warned of a fit by some sensation or symptom peculiar to themselves individually; one feeling heat, pain, and dryness of the eyes ; another, heat, redness, and swelling of the nose ; a third, an unusual craving for some particular kind of food, or some peculiar feel- ing at the stomach, &c. Palpitations or inter- nal flutterings ; severe cough, with mucous ex- pectoration ; irritability of the bladder, the urine being loaded with mucus ; a discharge from the urethra, with scalding or difficulty in passing the water ; unusual lassitude, and inaptitude for mental exertion ; peevishness, irritability of temper; depression of spirits, more rarely an unusual hilarity; and various other symp- toms severally precede the paroxysm in differ- ent cases. 4. With more or less of these indications of constitutional disorder, the patient often expe- riences chills or rigours, followed by heat, flushings, headache, and the sensations refer- rible to the part about to be chiefly affected These sensations, however, may have already appeared ; but they are now more evident, and are increased during the night. The patient complains of weakness, tenderness, achings. numbness, prickings, or shooting pains, with spasms, or a tingling sensation, in the limb; or of stiffness and weakness of the joints. A dark hue of the skin ; fulness of the veins ; swell- ings of the feet after exercise ; disappearance of an accustomed moisture from the soles, with remarkable dryness and heat; and frequent change of position of the legs and feet, espe- cially in bed, with general restlessness, are among the more constant precursors of the fit One or both feet, particularly the soles, and the balls of the great toes, become burning hot; sometimes, however, they are cold, and are kept warm with difficulty; frequently the chil- liness and coldness of the extremities alternate with feverishness, flushings, flying pains, and vertigo. Some of these symptoms, particular- ly the twitchings or cramps in the limbs, are felt chiefly when about to fall asleep, and are attended or followed by restlessness or watch- fulness. Local signs of premonition are most common in persons who have experienced pre- vious attacks. Where concretions have form- ed, severe pricking pains, with increased ten- derness, are generally present. In those of an inflammatory diathesis, or who are plethoric, exposure to cold, or other exciting causes, mav induce internal disease, with all the characters of idiopathic inflammation, which may continue for a longer or shorter time, and suddenly sub- side, being quickly followed by a regular par- oxysm of gout; such instances, however, be- long to a form of the disease hereafter to be noticed. 5. B History of the regular Gouty Paroxysm —a. The first fit of gout, although commonlv ! preceded by more or less of the above symp. GOUT—Acute—History. 39 toms, sometimes occurs while the patient is in apparent health ; but, even in this case, there have been indications of an inflammatory diath- esis, or of vascular plethora, with slight dis- order of the digestive organs. Most frequently he is suddenly awakened about midnight, or at one, two, or three in the morning, with severe throbbing pain in the affected part—commonly the ball of the great toe of one foot, attended by heat, stiffness, and a sense of distention and weight. These sensations increase to burning, with an actual augmentation of the temperature of the part, and with occasional severe stound- ing, or darting pains up the limb. Restless- ness, watchfulness, and fever increase, or con- tinue till about six or seven in the morning; when a gentle perspiration breaks out, followed by abatement of the symptoms, and some sleep in the slighter cases. The integuments of the part affected are swollen, slightly red, some- times shining as if varnished ; and the veins proceeding from it are remarkably full. In se- vere cases, but slight remission of the symp- toms occurs for two or three days. More com- monly, however, the symptoms abate in the day, but return, often with increased violence, at night, or shortly before midnight, and last till about five or six in the morning ; the integ- uments have now become of a vivid or scarlet red, and admit of slight pitting on pressure. The pain is shooting, throbbing, intense, and gnawing, with an unpleasant sense of heat, burning, or weight. The least compression or touch of the joints cannot be endured. 6. b. The constitutional symptoms of the par- oxysm vary with the severity of the attack and the previous health of the patient. Fever is * generally present, and commences as stated above. It is attended by restlessness, thirst, loss of appetite, oppression at the praecordia, flatulent distention of the stomach, with ab- dominal pain, costive or irregular bowels, mor- bid evacuations, and scanty high-coloured urine, depositing a pink or brickdust sediment after standing, and sometimes containing mucus. The pulse varies, but is generally full or hard, and quicker than natural. Pain, heat, and ten- derness of the epigastrium, with spasmodic sen- sations referrible to the stomach, are frequently complained of, and are attended by sour eruc- tations, or vomiting of acrid or acid matters, sometimes mixed with bile, and causing un- pleasant irritation of the pharynx and fauces. The tongue is furred or loaded, the papillae erect, and the edges and point red. The stools are offensive, mixed with mucus, sometimes pale or clayey, but more frequently foul, black- ish, or of an olive green. The symptoms allo- gether evince more or less irritation of the gas- tro-intestinal mucous surface, with obstruction or vitiation of the biliary and intestinal secre- tions. In old cases, and in persons far advan- ced in life, the attendant fever is much less inflammatory, and sometimes partakes more or less of the nervous character. In most instan- ces, the nervous system evinces disorder by irritability of temper, increased sensibility, rest- lessness, and darting pains in the course of the nerves, very generally attended by violent cramps or spasmodic contraction of the mus- cles of the affected limb, and sometimes follow- ed by the sudden transition of the disease from one limb to the other. Almost anv change of posture produces this spasmodic action, and the severe pain attending it. Sir C. Scudamore states, that of 120 cases, cramps occurred in 90, with more or less severity, either upon the accession of the paroxysm, or during its height, or at its close, or even during all these periods. 7. c. A first attack may continue from two or three days to ten or twelve. The oedema re- mains a short time after the inflammation, which disappears with desquamation of the cuticle of the part, and much itching. Some- times the disease appears in the other foot, giving rise to the same succession of disorder, often with greater severity and prolonged du- ration. Sir C. Scudamore thinks that the first attack is more frequently mild in men than in women ; and states that of 198 cases, the great toe of one foot only was affected in 130 ; the great toe of both feet in ten ; the great toe and instep in three ; the instep of one foot in five ; the instep of both feet in three ; one ankle in ten ; both ankles in one ; the ankle and instep of one foot in four; the right knee and left hand in one ; the back of one hand in two ; and the wrist in one; various parts of the lower extremities, especially of the feet, being affect- ed in the rest. He farther remarks that, in hereditary gout, the great toe is mostly the part first affected; and that the exceptions to this seat of a first attack are chiefly met with in persons who have acquired the disease. 8. d: The frequency of the returns of the fit depends upon the constitutional tendency, the treatment, and the regimen, and mode of life of the patient. Although the disease generally returns to the part previously affected, the other foot seldom escapes. Each succeeding seizure is usually more severe and of longer duration than its antecedent, and the attendant consti- tutional affection more serious. Exceptions, however, to this may occur when the disease has been treated with judgment, and the pa- tient has been careful of his health. The in- tervals also become shorter, and the parts af- fected more numerous ; but the fits are most apt to recur early in the spring or late in au- tumn, probably owing to the variability of the weather at these seasons ; but they may occur at any season. The malady generally acquires strength with each returning fit, both as to the number of parts affected, and as to the duration and degree of suffering caused by it; the sus- ceptibility to it increasing both locally and con- stitutionally with the repetition of the attacks. 9. e. In some persons the gout seizes only the feet; but, in more numerous instances, in its progress, several parts are attacked in the same paroxysm; the gouty inflammation af- fecting different places in succession, or at the same time, with equal or various degrees of severity. The feet, ankles, knees, and elbows are occasionally thus successively or simulta- neously attacked ; together with the ligaments, the bursa; mucosae, sheaths of tendons or apo- neuroses. In the older cases, even the shoul- ders and hips are sometimes affected. The disease often suddenly leaves one part, and as instantly appears in another; but it occasion- ally commences in one situation before it de- parts altogether from the other. This rapid transfer of the morbid action from one part to another, either of the same or of a different limb, is one of the most characteristic phenom-. 40 GOUT—Chronic. cna of gout. When it thus passes to the oppo- site limb or extremity, some indications of the disease have often existed previously in that part. In a few instances, the chief suffering of the patient is in the day ; in others, both day and night are passed in equal pain ; but in most cases, particularly in the more recent attacks, the night is the period of greatest distress. The redness and cedematous swelling are most remarkable in the foot, hand, and elbow. In the ankle, knee, wrist, &c, there is little red- ness, excepting in small patches, and the swell- ing is caused by effusion into the sheaths of tendons, and into the bursae ; the latter often being greatly distended, painful, and exquisite- ly tender. In the more severe cases the veins of the limb are large and full, and unusually numerous near the affected part. The pain in gout is peculiar—is severe, burning, throbbing, shooting, or stounding, and otherwise modified in different cases, as stabbing, cutting, boring, or gnawing. 10. C. The Sequela of Acute Gout respect, 1st. The effects of the disease in aggravating previous derangement, or inducing disorder of internal organs ; and, 2d. The alterations pro- duced by it in the part affected.—a. Severe at- tacks of gout impair vital power in the digest- ive, biliary, and nervous organs ; or they may be said, with greater accuracy, to weaken still more the previously debilitated organic nervous influence. Hence occasionally result a numer- ous train of dyspeptic symptoms; hypochon- driasis, and torpid or otherwise deranged func- tion of the liver; inaction of the caecum and colon, causing a sluggish state of the bowels and morbid evacuations ; increased liability to apoplectic and paralytic seizures, or to cramps, wandering pains, &c. Sydenham supposed that gout disposed to the formation of urinary calculi; and numerous cases have been record- ed in which either they or gravel in the urine alternated with the gouty paroxysm. This connexion has received support from the ob- servations of Morgagni, Schurig, Buechner, Shroeder, Mursinna, Heim, and Forbes ; but Sir C. Scudamore states that irritation of the urinary organs and gravel occur rather before and during the paroxysm than in the interval; and that calculus of the bladder is a very infre- quent complaint among gouty persons; of 231 of whom five only were so afflicted. This, however, does not altogether disprove the con- nexion ; as renal calculi may have existed in some, if not in many of these. He, however, adds that the urine of gouty persons deposites, without any exception, at some period or other, either gravel or the pink or brickdust sediment. There can be no doubt that the gravel is form- ed either in the kidneys or in the urinary blad- der ; and if this be granted, a strong argument will be thereby furnished in favour of the occa- sional supervention of calculi. 11. b. The most frequent consequence of acute gout, as respects the local affection, is the passage of it into the chronic form ; but before this degeneration may have taken place, several lesions of the tissues composing the part affected may be produced by acute attacks. These are, weakness, stiffness, and lameness of the joint, with a snapping or grating sensa- tion upon motion, owing to imperfect secretion .of the synovial fluid. The ligaments and mus- ; cular aponeurosis become thickened, stiff, ot inelastic, and tender. The secretion from the sheaths of the tendons is thickened or other- wise vitiated, causing a knotty and thickened feel upon examination, sometimes with con- traction and rigidity. The bursae mucosae are enlarged, and either distended or soft and yield- ing to the touch. The contents of the small bursae are sometimes inspissated so as to form hard tumours ; and the deep-seated textures of the joints become thickened and apparently consolidated. The veins of the feet and legs are often either enlarged or varicose ; but these, as well as various other changes, as concre- tions, &c, are chiefly the result of the chronic disease. 12. ii. Chronic Gout—a. This state of the disease is characterized by the inflammation and pain being more slight, irregular, and wander- ing than in the acute; by the faint redness of surface, the permanent distention and oedema of the part; by impaired power of motion ; by its more continued duration, and association with disorder of the digestive organs ; by the languid or oppressed circulation; and by gen- eral irritation of the nervous system. It is generally a consequence of one or more acute ! attacks, either when the paroxysm has not passed off with a regular crisis or evacuation, or when repeated seizures have so enfeebled the constitution as to render it incapable of manifesting sthenic action. It may, howev- er, appear primarily, constituting the Primary Chronic Gout of J. P. Frank. In this case, in- stead of severe paroxysms occurring at distant intervals, the seizures are much milder, but much more frequent, prolonged, and irregular. Primary chronic gout is more common among women than men, and in them, especially, sel- dom affects the great toe ; sudden swelling and pain, with but little of the appearance of the gouty inflammation, affecting chiefly the instep or ankle, or the wrist or hand. When chronic follows acute gout, the various parts which had been inflamed in the paroxysm of the latter continue affected, either alternately or in con- junction ; but the pains are more wandering, and have now and then a rheumatic or nervous character. 13. b. Whether primary or consecutive, chron- ic gout presents the following local symptoms: A sense of alternate heat and coldness is felt in the affected part, and is much increased at night. There are often numbness and an un- easy sense of fulness and weight. The mus- cles and joints feel weak, and cramps of the lower limbs occur chiefly at night, when falling asleep. Startings and restlessness are gener- ally also complained of. The surface of the part is either of a pale reddish colour, or of the natural hue, or of a purplish tint, the discolora- tion being sometimes transient. The parts are tender; shooting pains pass along the nerves; motion is difficult and painful; and the energy of the limb very much impaired. The bursa? and the sheaths of tendons are more frequently affected in the chronic than in the acute gout, occasioning puffiness and distention. CEdema is generally present and permanent, attended by fulness of the veins. Even in the slightest cases, aching and a sense of heat are felt in the ankles after walking. 14. c. The constitutional symptoms are remark- GOUT—Irregular. 41 ably diversified by the temperament and habits of the patients, the situation and degree of the local disease, and by the nature and extent of the internal associated disorder. Numerous dyspeptic symptoms and uneasy sensations re- ferrible to the stomach, as craving for food, nausea, oppression after a meal, flatulency, heartburn, a sense of coldness at the stomach, transient pains or spasms of the muscles of the abdomen or chest; a costive or irregular state of the bowels, with morbid or offensive stools ; a deficient or unhealthy biliary secretion ; and haemorrhoids, with evacuations of blood, are often present. Feverishness or irritation fol- low too full a diet, or stimulating food; and a sallow or slightly yellow cast of countenance, with uneasiness or pain in the hypochondria, and deficiency of bile, are not infrequent. The urine is various, being sometimes scanty, high- coloured, or thick, or occasionally abundant and dilute; it generally deposites a pink or lateritious sediment. Palpitations and flutter- ings of the heart are very common, particu- larly when there is much flatulence. Sleep is broken, disturbed by unpleasant dreams, and unrefreshing; the temper is irritable, and the mind hypochondriacal, imaginary or trifling ills occupying the attention. In some cases a chronic dyspeptic cough, or an increased secre- tion of mucus in the trachea, is complained of. Many persons, especially females, are exqui- sitely sensitive, and have their ailments in- creased by vicissitudes of atmosphere, espe- cially by cold and humidity. In prolonged or severe cases the system often becomes cachec- tic ; the limbs weak, stiff, and wasted, and the abdomen large. Although the patient's appe- tite may be natural, yet he is neither nourished nor strengthened by his food, which may even increase both the constitutional and local af- fection. 15. d. The concomitants or consequences of prolonged chronic gout are thickening and con- solidation of the tissues of the affected part. The veins of the limb often become varicose, and increase the achings and fulness of the part, or cause purplish blotches of the surface, and, although rarely, ulceration of the skin. Gouty concretions occur only in a few cases, and arise from the effusion of a whitish fluid, the watery portion being absorbed. Mr. Moore remarks that this effusion occurs not only during the fits, but also in the intervals ; that it is not en- closed in a cyst, but usually lies in the cellular membrane, in the bursae mucosae, or in the cav- ities of joints. In the sheaths of tendons these concretions are generally hard or stony ; in the bursae they are likewise hard, and in the cellu- lar tissue their consistence varies. They may also form between the cuticle and cutis, where they vary in consistence, or even occasion in- tractable deep ulcers, as in a case related by Mr. Herbert Barker. When they are situa- ted within the capsular ligaments, the cartilage is absorbed, and one or more phalanges dis- torted. Sir C. Scudamore mentions several such cases. When the concretions cause ul- cerations, the chalk-like matter is constantly secreted in a fluid or semifluid state, and ac- cumulates in the bottom of the ulcers* The * " An officer of temperate habits, who had undergone much active service, was, for some years before his death, Etat. 45, much affected with gout; many balls of chalk 6 surrounding surface is usually of a red colour, shining, and the seat of severe burning pain, symptoms occurring in paroxysms, with remis- sions or intervals of various duration. In such cases, erythema or erysipelas may be associa- ted with the local affection. Although the concretions generally appear in the joints and surrounding tissues, they may occur in other situations, either simultaneously or otherwise. Morgagni mentions their formation in the breast of a patient suffering from hereditary gout. In the case detailed by Mr. Barker there was a gouty concretion, of the size of a horse-bean, deposited on the left side of the nose. Dr. Elliotson met with a case in which they formed in the ears. Their chemical con- stituents seem to be lithic acid combined with soda, potash, or ammonia, but mostly with soda, and with a little animal matter. They are of a light or whitish gray colour ; insoluble in cold, and partially insoluble in boiling water. 16. iii. Irregular Gout.—Under this head may be arranged the various states of disorder either occurring in the gouty diathesis, or con- nected with the appearance of the gouty par- oxysm, or following its sudden cessation in an external part. In this extended acceptation of the term, irregular gout will comprise the brief consideration of those derangements to which the names anomalous, imperfect, internal, visce- ral, misplaced, displaced, relrocedent, transferred, metastatic, wandering, flying, disguised, masked, &.c, have been applied. I shall therefore con- sider, 1st. Those specific or anomalous disor- ders appearing in the gouty diathesis, and fol- lowed by a complete or imperfect external gouty affection ; 2dly. The derangements con- sequent upon the sudden cessation of the gouty paroxysm ; and, 3dly. The various anomalous or disguised affections affecting persons of the gouty diathesis, without being followed or at- tended by any manifestation of external dis- ease. It has been urged by some modern au- thors, and even by the latest writer on gout, Dr. Barlow, that several of the forms just al- luded to are merely internal disorders occurring in gouty persons, and differing in their nature and treatment, in no respect, from those usu- ally observed; or, in other words, that these internal affections possess no specific gouty character. This is true in one point of view only, but not in others; for it must be admitted that the gouty are even more liable to internal diseases than healthy persons, and that these diseases will often pursue the usual course in the former as well as in the latter. That the gouty are very liable to nervous and functional disorders, especially those implicating the di- gestive and excreting functions, and that those disorders often present nothing peculiar, are generally admitted ; but that many of the af- fections which either precede or follow the external manifestation of gout, or that appear in the gouty diathesis, differ very materially from those observed in other persons, is shown by the following circumstances : 1st. Gouty inflammations of the eye are very different in their visible characters, their seats, and were removed from his hands, and he could write on the table with the point of his finger. Ulcers had also formed on his feet, which usually discharged an ounce of fluid chalk in the 24 hours."—(Catal. of Prepar., Ac,in the Mu- seum of Fort Pitt, &c, p. 167.) 42 GOUT—Irregular. their consequences, from common ophthalmia ; and every one possessed of due powers of dis- crimination will admit that they require a dif- ferent mode of treatment. 2dly. The knowl- edge we possess, however imperfect it may be, as to the changes and appearances consequent upon fatal internal disease in gouty persons, is conclusive of a material difference between them and those following more common mala- dies ; and, 3dly. The juvantia and ladentia in the former are often very different from those in the latter. 17. A. Specific or anomalous affections often precede the external manifestation in a complete or imperfect form of acute or chronic gout. They may be either in every respect similar to other affections of the same seat, or very dif- ferent and peculiar. In the former case, the external appearance of gout seems critical, and has been viewed as such by many writers ; in the latter, it appears as the external mani- festation of a constitutional disorder previously implicating the functions or sensibility of one or more internal organs. In perusing the older writers, numerous instances present them- selves of gout supervening upon, and appear- ing critical in inflammatory and severe inter- nal complaints. Morgagni considered himself cured of an ophthalmia that had resisted treat- ment, by an attack of gout. Dr. Baillie men- tions a case of palpitation of the heart disap- pearing upon the occurrence of the gouty paroxysm, but these are not rare occurrences. Indeed, palpitations of the heart are frequently symptomatic of the disorder of the digestive organs ushering in the seizure. Affections of the urinary organs, erysipelas, asthma, and other diseases have likewise been removed by a regular fit of gout. One of the most inter- esting illustrations of the succession and criti- cal influence of gout upon dangerous internal disease occurred to a medical gentleman whom I attended in 1824. He was seized in the evening with symptoms of complete congestive apoplexy, for which he was bled and purged, but without restoration of his consciousness. On the following morning gout suddenly appeared for the first time, with great intensity in the ball of the great toe of the right foot, and in- stantly removed all the apoplectic symptoms, the mental functions being perfectly clear and undisturbed on my seeing him very shortly af- terward. When gout assumes a regular char- acter, such antecedent affections appear merely as unusual precursors of the paroxysm, usher- ing in either the first seizure, or an attack in persons who had been previously affected by it. 18. B. Retrocedent or displaced Gout ; rece- dent, or transferred, or metastatic Gout; Podagra retrocedens; P. retrograda, Cullen; P. compli- cata, Good.—a. During the gouty paroxysm in either its acute or chronic form, it sometimes happens that an internal organ becomes sud- denly and dangerously affected, the external disease being either much mitigated or having entirely disappeared. It has been disputed whether the internal disorder arises from the suppression or subsidence of the external af- fection, or whether the latter disappears in con- sequence of the occurrence of the former. Either may take place, as evinced by the suc- cession of morbid phenomena in different ca- ses ; the development of disorder in an internal organ deriving it from external parts in some instances ; and the suppression of external manifestation of a constitutional disease de- termining it to an internal predisposed viscus in others. When retrocession occurs in the height of an acute paroxysm, the superinduced malady is generally also acute, and rapid in its course ; but when it takes place in the chronic form, it is often less severe and more prolong- ed. The internal affections which thus arise are generally caused by the patient's impru- dence by his habit of body and temperament, by previous disorder, or by injudicious treat- ment and management. The stomach is most liable to be affected, severe pain and spasm, with sickness, being complained of. The in- testines may be also attacked, either alone or in conjunction with the stomach, with all the symptoms of acute inflammation ; either form of disease often pursuing a violent or rapidly fatal course. Severe pain in the head, and symptoms of inflammation of the brain and its membranes, stupor, coma, apoplexy, epilepsy, or palsy supervene in some cases, especially in those who have previously evinced a tendency to these maladies. In other instances, affec- tions of the chest appear, particularly dyspnoea, sense of suffocation, oppression at the praecor- dia, with or without cough or expectoration. In some, pain or constriction in the region of the heart, violent palpitations, oppressed breath- ing, urgent anxiety, syncope, or leipothymia, &c, occur, indicating a serious affection of the heart or pericardium. In a case of this de- scription recorded by Mr Brown, and which terminated fatally some months after the dis- appearance of gout, the pericardium was thick- ened, and contained six ounces of bloody se- rum ; the heart was greatly enlarged, and its substance was pale, soft, flaccid, and attenua- ted, its internal membrane being of a deep vio- let colour ; honeycombed ulcers were also observed at the root, and in the arch of the aorta. Other diseases of an inflammatory, spasmodic, or nervous character, or of these mixed, may follow the disappearance of the external gouty affection, more particularly dys- entery, hepatitis, peritonitis, and various affec- tions of the urinary or uterine organs. Dr. Cullen mentions strangury, catarrhus vesicae, and haemorrhoidal affections among those not infrequently alternating with gout ; and in- stances have occurred to myself, as well as to Sir C. Scudamore, Mr. Howship, and many others, of the transference of the morbid action to the kidneys, causing suppression of urine, or inflammation with partial suppression; or to the neck of the bladder with severe spasm, or even to the prostate gland. Mr. Howship mentions that when gout is transferred to the kidneys, the urine becomes albuminous as well as scanty. Dr. Home states that a gentleman who exposed himself to cold and wet. while affected by gout in the feet, was in a few hours afterward affected by enteritis, which proved fatal in twelve hours; and Sir C. Scudamore mentions that Dr. Parry met with two instan- ces of extravasation in the brain in the same winter, after repelling gout from the extremi- ties by immersing them in cold water.* * [Gout is sometimes transferred to the spinal marrow, where it causes inflammation and softening of its substance attended with a variety of anomalous symptoms, and terini- GOUT—I RREGULAR. 43 19. b. The information we possess as to the lesions produced by the transference of the morbid action to an internal part is extremely imperfect; many who have the opportunity not giving themselves the trouble to inquire respecting them, or supposing that little or no alteration may be expected in such cases. Others, again, believe that the changes consist chiefly of those produced by inflammatory ac- tion. Without disputing that the consecutive affection is frequently inflammatory, I have seen it, in several instances, possessed of a distinctly nervous and spasmodic character, or consisting chiefly of remarkable depression of power, with the abolition of the function of the organ principally affected, and most intense suffering. A medical friend some years ago, whom I attended in the disease, took, contrary to my wish, and previously to removing biliary accumulations and morbid excretions, a large dose of colchicum, and was very shortly after- ward seized with violent pain in the stomach, a sense of sinking, and languid, small pulse, the gout having instantly disappeared from the foot. I soon afterward found him in the ut- nating often in hemiplegia. Such a case lately occurred under our treatment, in an old gentleman of seventy, who had all his life been subject to frequent and painful gouty attacks, but which had, in consequence of a more temper- ate mode of living, nearly disappeared. The disease came on gradually, with a painful sensation through the upper dorsal vertebrae, shooting through the chest, and causing embarrassed respiration, disturbed sleep, sediment in the urine, &c. These symptoms gradually increased till com- plete paraplegia ensued ; and after lingering about a year and a half from the commencement of the spinal affection, he sank under the disease. Dissection revealed softening of the spinal marrow opposite the lower cervical and upper dorsal vertebne, and other appearances indicating an in- flammatory condition. Dr. Graves has also described cases of disease of the spinal cord connected with, and apparently caused by, gout, in some of which the symptoms were very similar to those above described. In one instance the patient was subject to attacks of severe colic, preceded or followed by a gouty affection of the feet. After several of these attacks, he became affected with great weakness of his wrists, with pains in his fingers, particularly in the last joints. As the disease progressed these pains became- mure intense and extensive, till at length paralysis of the upper extremities came on, which was soon followed by that of the lower. Shortly after the paralytic affection had thus decidedly shown itself, he had an attack of gout in his feet (a circum- stance which also occurred in our own case), and this was followed by several others in succession. After each at- tack of pain in the feet, the paralytic state of all the limbs increased, and if he gained a little strength in the intervals between these attacks, a recurrence of the paroxysms al- ways made him worse than before. On examination after death, the spinal cord was found to be softened to the con- sistence of thick cream, opposite to the last cervical and first dorsal vertebra. The eye, also, according to Dr. Todd (On Gout, Rheu- matic Fever, Ac, Lond., 1843), is liable to be secondarily affected in gout, but only after severe attacks of the disease in other parts where the diathesis is thoroughly establish- ed. It attacks most of the various textures of the eye in succession, and ultimately destroys vision. The conjunc- tiva and the sclerotic are first affected, then the choroid and iris, the latter of which forms adhesions to the neigh- bouring parts, and these intercept the rays of light. It is probable that the retina also suffers. Mr. Wardrop thinks that the eye may be primarily attacked in gout, and gives a case in illustration of a gentleman who suffered from ar- thritic inflammation of the eye, accompanied by severe pain in the head, which was relieved by sinapisms to the feet so powerful as to cause ulceration. A connexion between apoplexy and gout has long been known ; the urethra and bladder are also peculiarly obnoxious to the disease ; but the affection of these parts generally precedes the develop- ment of the gout in the joints, and is relieved when it ap- pears externally. The bronchitis which occurs in gouty subjects seems to be of the same kind. These diseases, un- iier such circumstances, are most readily relieved by bring- ing back the gout, by stimulating epithems to its original scat] most agony, and prescribed large doses of camphor, with other diffusible stimuli, and mustard cataplasms to the feet. The gout as instantly returned to the extremities, and the affection of the stomach disappeared. A med- ical man, lately resident in Crawford-street, experienced, in 1830, an imperfect attack of gout in the feet. When I saw him, it had just forsaken this situation, and in twenty-four hours it successively had attacked the bowels, in the form of most violent colic, the diaphragm, and lungs, causing the most urgent dyspnoea ; and, lastly, the head, in a slight degree. The disease then appeared in one foot, and after- ward transferred itself to the other. In these cases the phenomena of internal disorder were those of severe nervous affection, probably also connected with congestion, or irregular determination of blood ; and the treatment founded on these views procured relief in them all. 20. Formerly the internal affections thus con- nected with the disappearance of gout were too exclusively viewed as nervous, and treated as such, notwithstanding the indications of in- flammatory action sometimes attending them. More recently, and even at the present day, a very opposite opinion has been promulgated. Dr. Gregory, of Edinburgh, supported this lat- ter opinion, and was followed in it by Dr. Bate- man and Dr. Barlow. Fully admitting the in- flammatory character of these consecutive af- fections in some cases, I must strenuously con- tend that it does not constitute the principal feature of them in others. In several instan- ces, three of which occurred in medical men in this city, any inflammatory state could not be inferred either from the sensations of the pa- tients, or from any symptom that I observed; and as the treatment founded upon the gouty and nervous characters of the disease was suc- cessful, there is no reason to infer that a latent inflammation had existed in these cases. That inflammatory and congestive affections of va- rious internal viscera often occur in such cir- cumstances cannot be disputed ; but the prac- titioner should be prepared to meet also with very different and often anomalous disorders— to find some attended by the most intense suf- fering and distress ; others by a feeling of sink- ing or dissolution; others by distressing anx- iety, terror, and irritation ; others by spasmo- dic action and morbid sensibility; and, lastly, others by constant pain, internal heat, disten- tion, tenderness, and other indications of in- flammatory action. In some, the pulse is weak, irregular, fluttering, small, or intermittent; in others, excited, frequent, irritable, but regular, or full, strong, and energetic. I have even seen it all these in succession in the same ret- rocedent affection, and within a few hours. Some cases, even where the same organ is implicated, are attended by constant pain, a sense of increased heat or of burning, remark- able tenderness, and excited pulse; and oth- ers by remaikable depression, great langour, a sense of coldness or of weight, or oppression, a weak and languid pulse, and a feeling of vital exhaustion and of impending dissolution. Of the pathological relations of these different morbid conditions more particular notice will be taken hereafter (§ 40-42). 21. C. Disguised or lurking Gout—anomalous, 44 GOUT—Diagnosis. imperfect, internal, visceral, nervous, masked, or misplaced Gout—Podagra atonica, Cullen ; Po- dagra larvata, Good. The gouty diathesis may be generated in a constitution too weak to de- velop the local affection in the extremities. When this is the case, various disorders affect- ing internal organs, most frequently those of digestion and excretion, arise, and often as- sume anomalous or Protean forms, with func- tional or nervous characters, and even congest- ive or inflammatory states, as in retrocedent gout. In that variety, the internal disease is preceded by, and is rapidly consecutive of the disappearance of an external gouty affection ; but this variety is frequently unattended by any such affection, however slight or fugitive, al- though it may occur. It has been too generally inculcated that the disorders appearing in the gouty diathesis have nothing peculiar in their character, or different from those observed in other circumstances. This subject has been already sufficiently adverted to with reference to retrocedent gout; and the observations there made are equally applicable to those affections which appear in the lurking or disguised man- ner now being considered. When, in connex- ion with the generation of the gouty diathesis, the constitutional powers have been greatly im- paired, and the functions of excretion weaken- ed, numerous internal disorders result, wheth- er the patient may have experienced a fully formed fit of this disease or not. A fastidious or impaired appetite ; a sense of distention and flatulence; acid or acrid eructations, or nau- sea or vomiting; spasmodic constriction, or most painful oppression at the epigastrium; costiveness and violent colic; mental depres- sion, anxiety, or hypochondriasis ; palpitations or other irregularities of the heart's action; hemicrania, vertigo, and various affections re- ferred to the head, or even palsy, epilepsy, or apoplexy ; nervous excitement and irritability, with a sense of depression, and several other affections, sometimes present themselves, ei- ther with or without slight manifestations of gout in one or other of the external situations above enumerated. That those complaints are favoured by, and very often occur in the gouty constitution, cannot be, and, indeed, is not doubted. The question only is, whether these be of an inflammatory, or of a nervous, or of a mixed, or of a specific or peculiar character. That they are functional, chiefly, cannot be dis- puted ; but that others of a more decidedly in- flammatory or congestive kind may occur, as in cases of retrocedent gout, seems to be most consonant with the phenomena observed in dif- ferent cases, and with the pathology of the dis- ease, according to the view of it hereafter to be exhibited. Dr. Havgarth has recorded two most interesting instances of misplaced gout, causing arthritic carditis in the one case, and enteritis in the other ; and, although an attack of gout had not been experienced for many years, moderate depletions, and sinapisms ap- plied to the extremities, were followed by the external gouty disease. 22. It is not unusual to hear persons who are advanced in life, and who have ceased to have their usual attacks of gout, complain of various nervous or functional disorders of so remarkable and peculiar a kind, as to convince them that gout is affecting or wandering through the system without developing its usual effects. Sir C. Scudamore very justly observes that some gouty persons are affected with severe colic upon accidental exposure to wet and cold, or from acid or indigestible articles of diet, and that almost invariably these attacks are spasmodic, and not inflammatory; hot brandy and water, or compound spirit of ammonia, giving relief. It should, however, be recol- lected that the continuance of pain may cause congestion of, or inflammatory determination to the affected part. The internal complaints occurring in the gouty diathesis are generally attended by sensations so distressing, and oft- en so peculiar, as to excite suspicions of their nature in the mind of the patient, and to cause him to desire an attack of gout, however se- vere, in the extremities, believing that it will remove the internal and more dangerous suf- ferings. Sir C. Scudamore defines these af- fections " to be disordered functions of internal organs in a gouty constitution, and thereby modified in their character ;" and in this opin- ion he has been followed by Dr. Barlow and others. Dr. Cullen, and those who preceded him, distinguished these complaints by the term " misplaced gout;" and, as it will appear in the sequel, the difference between the ideas intend- ed to be conveyed by these terms is more ap- parent than real; for the one, in admitting that such complaints are modified by the gouty di- athesis, concedes all that is contended for by those who distinguish them by applying to them, without circumlocution, a term indicating at once their most important features and rela- tions. 23. II. Diagnosis.—A. Acute Gout may be mistaken for acute rheumatism, which it may ap- proach more or less near, when the latter af- fects the joints, or for common inflammation of these parts. It seldom happens that more than one part is affected, and still more rarely that more than one is attacked at the same moment in the first fit of gout. This character, however, cannot be extended to acute rheumatism. In the former there is much more disorder of the digestive organs, precursory of the attack, than in the latter, and the remission from pain and fever during the day is much more distinct. In gout, serous effusion into the cellular tissue is early in the fit, and to the extent of admit- ting of slight pitting on pressure; the veins are turgescent in the vicinity of the affected part; the pain is pungent, severe, burning, stounding, lancinating, or peculiar; the surface is inflamed, deeply red, shining as if varnished, turgid, and exquisitely tender; the temperature of the part is very much increased; and the urinary secretion is remarkablydisordered, gen- erally depositing a quantity of the pink or lat- eritious sediment, consisting of the lithate of soda, the tinging substance being the purpurate of soda. These symptoms are either absent or slightly marked in acute rheumatism. 24. The hereditary character of gout; the frequency of it in the plethoric, sanguine, and irritable constitutions, and at an advanced age • the sudden incursions of the fit; and the com- mencement of it in the small joints, farther serve to distinguish it from rheumatism al- though gout may affect the knees, shoulders. elbows, &c, after repeated attacks, or in its chronic form, it rarely commences in these sit- GOUT—Prognosis. 45 uations, whereas rheumatism generally begins in the shoulders and larger joints. It is some- times, however, observed that the patient, on recovering from the one disease, may be attack- ed by the other, upon exposure to its exciting causes ; and a person who early in life has liv- ed frugally and laboriously, and been subject to attacks of rheumatism, has, at a more advan- ced age, lived fully and indolently, and been at- tacked by gout. In either case, the patient himself has no difficulty in distinguishing be- tween them, and the experienced practitioner will have as little, however much he may be at a loss to convey his ideas respecting their di- agnosis to others. It is not so much by any one mark as by the concurrence of several cir- cumstances, connected with the causes, the constitutional disturbance, antecedent and ex- isting, and with the local characters, that a cor- rect diagnosis can be formed. Commoninflam- mation of the joints cannot be mistaken for acute gout, if the character of the pain, the state of constitutional disorder, and the urinary secre- tion receive attention. The continued or un- remitting state of the symptoms, and the course, progress, and termination of the disease, will also serve to distinguish them. 25. B. Chronic Gout may be distinguished from chronic rheumatism by several of the cir- cumstances already adverted to. The former is much more frequently preceded by the acute disease, and by disorder of the digestive and excreting functions, and is very much oftener attended by swelling, thickening, or nodosity of the affected parts than the latter. However, cases not infrequently occur in which gout, in its more chronic form, very nearly resembles chronic rheumatism, there being but little dis- order of the above functions attending them. In forming a diagnosis, the temperament, hab- it of body, age, and mode of living should be taken into consideration. Dr. Havgarth ob- served that only 14 patients out of 300, ill of chronic rheumatism, had swelling in the seat of disorder. It should, however, be recollect- ed that when chronic rheumatism affects the bursae mucosae and thecae of tendons, particu- larly those of the knee joint, considerable tu- mefaction takes place. Although the gout, in its chronic form, is still more fugitive than when acute, and thus approaches nearer to the na- ture of rheumatism, yet it is much more dis- posed to seize the hands and feet than that dis- ease, as well as to be more solitary in its situ- ation. The parts which have been often affect- ed with gout become very susceptible of chan- ges of temperature, and, in this respect, partake of the rheumatic character. Sir C. Scudamore thinks that it is only in this way that any pro- priety can be attached to the expression rheu- matic gout, and conceives that gouty and rheu- matic inflammations cannot both exist in the same part at the same time, although they may occasionally co-exist in different parts; as when a patient suffering gout in the usual sit- uations is seized with rheumatism in the mus- cles of the neck, or in the shoulder, or other parts, in consequence of exposure to currents of cold air, &c. When gouty concretions form, the nature of the complaint will be sufficiently evident. 26. C. It is a matter of great difficulty to discriminate between the internal affections characterizing irregular gout, and similar af- fections unconnected with this disease, as may be inferred from what has been already ad- vanced on the subject. It is only by applying sound principles of pathology to the investiga- tion, guided by much acumen and experience, that we can expect to distinguish between them. When called to a patient advanced in life, of the irritable and nervous temperament, complaining of violent sufferings, or of various nervous and functional disorders, or of severe spasmodic affection, we should endeavour to ascertain, from the state of the pulse and the temperature of the surface, from the sensations produced by a minute examination, from the appearances of the excretions, and from the history of the case, especially with reference to its causes and to previous attacks of gout, and to any hereditary predisposition to it, the ex- act pathological condition upon which the symptoms depend. The existence or non-ex- istence of inflammatory action, or the degree in which either may be mixed up with spasm or morbid sensibility, should be ascertained. Many writers, both previous to, and contempo- rary with Dr. Cullen, considered debility and spasm, with altered sensibility, to be more characteristic of retrocedent and misplaced gout than inflammatory action ; and this opin- ion seems to have been too generally, and often injuriously adopted. But I am convinced that, in more recent times, the opposite doctrine has been too exclusively confided in, and with lit- tle less injury as to the results. The practi- tioner, in all such cases, should be guided by pathological inferences derived from the phe- nomena characterizing individual cases ; and if he find the pain fixed, the pulse excited, or hard, or oppressed, the skin hot, and the parts tender or painful on pressure, he will deduce the existence of inflammatory action ; where- as, if the pulse be weak, small, irregular, or in- distinct, and compressible ; if the skin be cool, the countenance collapsed or anxious ; the surface relaxed and perspirable, the parts tol- erant of pressure, and if no unnatural sound be detected on auscultation and percussion, he will infer the presence of functional disorder merely or chiefly, or of spasm, or of depression of nervous power, with altered sensibility. 27. III. Prognosis.—The prognosis should vary with the form which gout assumes.—.1 In the regular acute disease a favourable opin- ion may generally be given, if the internal or- gans betray no serious lesion of function or of structure. The subsidence of sympathetic fe- ver, improvement in the excretions, the urine ceasing to deposite a sediment, or losing its high specific gravity; a return of the appetite, and of the spirits; desquamation of the inflamed cuticle, with disappearance of the swelling, are indications of recovery. The sudden transfer- ence of severe affection from one part to an- other, especially if accompanied with painful sympathy of the digestive organs, or with ner- vous symptoms and exquisite susceptibility, or with irregular fever, and with persistent disor- der of the excretions, are signs of a difficult and intractable disease. In this form of gout especially, the prognosis should be influenced chiefly by the state of the excretions; for as long as the stools and urine continue morbid, other signs of amendment will prove delusive. 46 GOUT—Causes. 28. B. The prognosis in chronic gout is more unfavourable than in the acute, as respects subsequent immunity from the disease. As to recovery from the seizure, the circumstances just stated will influence the opinion of the practitioner, as in the acute variety. In every case, however, the state of constitution and of internal organs, and the effects produced by treatment, should be taken into account in de- ciding respecting the duration or the event of the disease.—C. Internal affections, occurring either in the gouty diathesis or upon the sud- den disappearance of the external disorder, are always unfavourable in proportion to their se- verity, and the vital importance of the parts in which they are seated. When the heart, the brain, or the stomach and intestines are the seats of retrocedent or misplaced gout, the patient should be always considered in the utmost dan- ger, especially if he be far advanced in life, if nervous energy be much impaired, and if judi- cious treatment has not immediately produced the desired effect. Cases of this description, however, not infrequently recover when ap- propriate and decided means have been prompt- ly resorted to, and when the constitution of the patient has not been remarkably injured. 29. IV. Causes of Gout.—i. Predisposing Causes.—These may, as in other diseases, be- come exciting causes, owing to continued or energetic action.—a. Hereditary disposition has always been viewed as most influential in the production of gout. Cadogan, however, at- tached too little importance to it, and Cullen too much. It is very probable that it will evince various grades of influence in different classes or states of society—that it will seem of greater importance in those who live regu- larly, soberly, and laboriously; and of much less in those who are indolent, luxurious, or dissipated. Sir C. Scudamore states that of 213 persons afflicted by gout, 84 could not trace it either to the father's or mother's side. But it is probable, conformably with what has been just stated, that an unusually large pro- portion of non-hereditary cases will be met with among the indolent and luxurious inhab- itants of a large metropolis. Of the hereditary cases, 62 were derived from the father, 29 from the mother, 14 from both father and mother, 14 from the grandfather, &c. When both pa- rents have had the disease, a greater number of the children will experience it. Where one parent only has had it, the child or children having the greatest resemblance to that parent will be most liable to it. 30. b. Adult age, particularly from 25 to 50, is the period at which gout most frequently first appears. Sir C. Scudamore states that of 209 cases, 25 had the first attack between 20 and 25 years of age ; 38 between 25 and 30 ; 41 between 30 and 35 ; 37 from 35 to 40 ; 18 from 40 to 45; 25 from 45 to 50, and 11 be- tween 50 and 55. Gout is rarely met with be- fore puberty. Hippocrates first stated this fact, and it has been confirmed by Sydenham and many other writers. Heberden never saw an instance of it. Dr. Scudamore men- tions a case at 8 years of age. I treated one, many years ago, at 11, and am at present at- tending a boy of 9, recovering from a severe attack in the foot. Very early seizures have generally been observed where the hereditary predisposition has been strong. In the two cases just alluded to it existed in both pa- rents, and in one of them there was sjreat precocity of intellect. In some cases, where the disease appeared very soon after puberty, premature or excessive venereal indulgences seemed to me to have aided in its production 31. c. The male sex is much more disposed to gout than the female. Hippocrates men- tions the non-liability of females until the ces- sation of the menses This, however, is not correct; for cases occur at an early age in the plethoric through indolence and high feeding, and in those who have not had children. I met with an instance of it in a female of 27 years of age, who was thus predisposed. Dr. Greg- ory observed, in his lectures, that females sub- ject to gout had experienced menorrhagia, or had become plethoric from ingurgitation; and Dr. Cullen has remarked that robust and mas- culine females, before the menses have ceased, or those in whom they have been very abun- dant, are not infrequently attacked. The in- stances of gout which I have seen in this sex, previously to the change of life, have been chiefly in those who had suffered frequent or excessive menstrual evacuations, who had lived very fully and indolently, and who had not been pregnant. The relative immunity of females is evidently owing to their temperance, to their periodical evacuations, and to the dis- charges and secretions connected with child- bearing. 32. d. Habit of body and temperament.—Gouty persons are said to have capacious and circu- lar chests, with large full veins, and loose sol- ids ; but to this rule there must evidently be numerous exceptions. Sydenham remarks that the gross and corpulent, and those with large heads, are most frequently affected. J. P. Frank states that the gouty conformation consists of a large and full body, voluminous head, large bone, and thick skin. Sir C Scu- damore found that of 226 males, 64 were tall and corpulent, 41 middle height and corpulent, 25 short and corpulent, 28 middle stature and bulk, 14 tall and middle bulk, 21 short and mid- dle bulk, &c. ; and that of 28 females, 9 were tall and corpulent, 8 short and corpulent, 4 middle height and corpulent, and 4 short and slight. Corpulence usually precedes the dis- ease, and often increases with the progress of it. The gouty generally possess good consti- tutions, abused by indulgence. The sanguineo- nervous and irritable temperaments are the most liable to be attacked by gout, although other diatheses may be also affected. Cadogan as- cribed gout to three causes, which generally act conjointly, namely, indolence, intemperance, and vexation. Taking these in their wide sig- nification, their importance cannot be contro- verted. In whatever station of life they pre- vail, particularly indolence and intemperance, gout will appear as one of the most frequent re- sults ; hence it is not infrequent in butchers, innkeepers, and publicans ; and in butlers, coachmen, and porters in wealthy families, as well as in the more easy classes of society. It is, in short, met with in all occupations which conduce to inactivity and repletion. 33. e. Venereal excesses are among the most unequivocally predisposing causes, especially if associated with the intemperate use of animal GOUT—Causes. 47 food and of wine ; for while the former species of excess exhausts the nervous power, the lat- ter occasions plethora, and both combine to im- pair the functions of digestion, assimilation, and excretion ; hence the ancients said that gout was the daughter of Bacchus and Venus. The wines which favour most the production of gout arc Champagne, new port, and the clar- ets ; but other wines have more or less influ- ence, and are more productive of the disease than malt or spirituous liquors.* Strong malt liquor disposes to it even more than spirits. Dr. Cullen justly remarks that gout never at- tacks those following laborious occupations, or who live chiefly on vegetable food, or use neither wine nor other fermented liquors. Schenck, Van Swieten, and other authors have adduced numerous instances of persons who, during a life of luxury and indolence, had been subject to this disease, but had never af- terward suffered from it when their circum- stances required them to live abstemiously and laboriously. In countries where animal food and vinous or intoxicating liquors are little used, gout is almost unknown. The habit of partaking of a great quantity or variety of an- imal food is not less influential than other kinds of intemperance in causing the disease. Se- vere study has been considered to predispose to it; but this cause is merely apparent or in- direct, others of a less doubtful kind also ex- isting. The depressing passions are not with- out influence, inasmuch as they weaken ner- vous energy and the functions of digestion and excretion. A cold and variable climate favours also, in some degree, the formation of the gouty diathesis; and the changeable weather in spring and autumn, and the cold winds and humid atmosphere of these seasons have a sim- ilar effect. The disease is comparatively rare within the tropics, unless among those who have indulged in those habits which are most influential in predisposing to it; and yet two of the severest cases I ever saw occurred near- ly under the equator in Africa. 34. /. Functional disorder of the digestive organs is one of the most universal causes of gout. Many of the causes already noticed, and of those about to be mentioned, act partly by weakening these organs and favouring con- gestion of, or inflammatory determination to the mucous surface. It is not, however, a state of inflammation of this surface, but rath- er of vascular erethism, that is thereby genera- ted. Hence the appetite, instead of being im- paired, is often increased; and the patient is prompted to take more food than the stomach and collatitious viscera can digest and assimi- late. When the appetite is impaired, owing to the digestive mucous surface having assumed a more inflammatory state, frequent attempts are but too often made to excite it by stimula- ting and savory articles of diet; and the mis- chief is thereby augmented. Even where func- * [Dr. Alison remarks (Outlines of Pathology and Prac- tice of Medicine, Am. Ed., Phil., 1844, p. 219) that " those who drink fermented liquors to excess, as the London coal- heavers, although in other respects, particularly as regards exercise, in circumstances generally favourable to avoiding the disease, are frequently affected by it;" and Dr. W.Bwdd (Tweedie's Lib. of Med., 2d Am. Ed., iii., 587, Philad., 1842) states that " malt liquors tend, even more than wine, to produce a gouty diathesis," a remark which is confirmed by the experience of other accurate observers.] tional disorder only exists, inflammatory irri- tation is superadded, attended by the severer symptoms of indigestion ; by acrid eructations; by painful distention and soreness of the epi- gastrium ; by congestion and impaired action of the liver; by interruptions of the passage of bile into the duodenum, accumulations of it in the gall-bladder and ducts, and a redundancy of its constituents in the blood ; by acidity of the prima via, and an imperfect elaborated or unhealthy chyle ; and ultimately, as will be hereafter shown, by a morbid state of the cir- culating fluids. But these are merely acces- sories to the formation of the gouty diathesis ; other conditions, particularly vascular pleth- ora, being also required; and this state, with the various other elements of the gouty con- stitution, is that which is generated, in a great- er or less degree, by the causes now passed in review. 35. ii. Exciting Causes.—While the forego- ing causes act chiefly in generating the gouty constitution or predisposition, those about to be mentioned are mainly concerned in exciting or developing the paroxysm. The sudden re- pletion and inflammatory excitement of the vascular system, in connexion with irritation of the digestive mucous surface, produced by excessive indulgences at the dinner-table, fre- quently occasions a fit in a few hours, when the morbid diathesis is already formed ; and when the excess is repeated, particularly in quick succession, the morbid effect rarely fails to take place. Champagne excites an attack more certainly than any other wine. A lady under my care, and who had not passed her thirtieth year, always suffered more or less on the following day, after taking a single glass of Champagne ; but the excessive use of any wine, especially if new or of inferior quality, will pro- duce a seizure. The use of malt liquor during dinner, and of port wine afterward, will excite it, if active and regular exercise be not taken. Strong malt liquors and spirits will often have a similar effect, especially if much animal food be habitually eaten. It is not only indulgence in wine or other exciting liquors, or the admix- ture of them, that is injurious; for a great quantity and variety of animal food, and of highly-seasoned dishes, which they excite the stomach to receive until it is overloaded, are equally prejudicial. Acidity of the prima via, from the imperfect digestion of the mass of dif- ferent substances partaken of, inflammatory ir- ritation of the digestive mucous surface, disor- der of the biliary secretion and excretion, vas- cular plethora excessively or suddenly increas- ed on each of such occasions, and the accumu- lation of excrementitious and irritating matters in the blood, are the common consequences of these indulgences. In many cases, not merely acid, but acrid or acro-rancid combinations are formed by the imperfectly digested substances and the disordered secretions poured into the alimentary canal; and these increase or per- petuate the irritation of the mucous surface, while they exert upon the organic nerves a noxious influence, which is more or less mani- fested throughout the digestive circle, as well as the extreme parts of the frame. 36. Neglected or constipated bowels, and in- terruption of any of the excreting functions, will occasionally be followed by an attack, with- 48 GOUT—Pathological Conditions. out any cause having occurred that could have acted in any other way than this. Cold seems to operate, partly by suppressing the excretions, and partly by depressing nervous power. Its effects in exciting a paroxysm, whether applied to the general surface, or to the extremities, or to any part, are well known. Fatigue and exter- nal injury not infrequently produce an attack ; and the injured part is usually the seat, espe- cially in cases of sprains, contusions, or con- cussions. The passions of the mind, also, have no mean influence. All powerful mental emo- tions, whether exciting or depressing, will ex- cite a paroxysm ; but anger or vexation has this effect in a very remarkable manner. The an- cients made Anger to be the midwife of Gout; and Cadogan considered vexation, in its wide signification, as one of his three great causes of the disease. The depressing passions, par- ticularly fright, severe grief, anxiety, &c, may either occasion an attack, or cause its retroces- si m, or give rise to a misplaced affection, or to some one of the irregular states of the dis- ease noticed above, particularly in persons who have been formerly affected. Besides these, mental and bodily labour, especially when they abridge the requisite duration of sleep; the sudden cessation of habitual evacuations and excretions, as of the catamenia, haemorrhoids, the sudor pedum, &c.; cold, flatulent fruits or vegetables, and acidulous liquors or beverages ; sudden changes of diet or regimen ; and what- ever disorders the digestive and excreting or- gans, or suddenly impresses the nervous sys- tem, may excite the gouty paroxysm, either when the predisposition has been fully formed, or when an attack has been experienced. It is from a combination of two, or several, or even of many causes, that the disease is occasioned, especially if it appear independently of any he- reditary taint. In a few instances, this taint seems almost sufficient to produce it, without the aid of any manifest intemperance. This remark was made by Galen, and Haller and Others have confirmed it. Cases sometimes, also, occur of persons entitled by both parents to be subject to the disease, who have es- caped it, although they lived intemperately. Quarin states that he knew two brothers, sons of gouty parents ; one of them lived so- berly and laboriously, yet was horribly affect- ed with gout; the other exposed himself to its common causes, and altogether escaped it: but these are rare exceptions from the general course of events. It appears that females fre- quently acquired gout in ancient times, inas- much as Seneca (Epist. 95) mentions the cir- cumstance as a proof of the depravity and lux- ury of his age. 37. V. The Pathological Conditions on which gout depends may be inferred from what has been already advanced as to its causes and phenomena.—a. The older writers imputed it to a peculiar morbid humour existing in the blood. This materies morbi has been somewhat differently explained. Galen considered that it may be phlegm, or a mixture of phlegm and bde, or even blood, or all these, or simply a crudity of the circulating fluids ; and that the gouty concretions arise from the crude hu- mours. Psellus believed that it is a thick humour generated and collected by an atony of the nutritive fa:ulty. Alexander Tralli- i anus contended that the defluxion of humours I occasioning gout is various, according to the local changes and symptoms existing in differ- ent cases—that they are bilious, phlegmatic, , melancholic, or even sanguineous ; and that these occasion pain by getting between the ten- dons and ligaments, and distending and irrita- ting them. Aetius maintained the disease to arise from a redundancy of humours caused by weakness of the part affected. C.elius Aurb- lianus assigned the remote cause of gout with great accuracy, and explained its nature in a nearly similar manner to the preceding writers. Paulus ^Egineta considered that a preternat- ural humour and a weakness of the parts com- bine in producing the disease ; and that the re- mote causes, which he enumerates very cor- rectly, generate indigestion and a cacochymy, whence proceed various morbid humours, which are bilious, melancholic, or sanguineous, but. for the most part, pituitous and crude, owing to excess of food and want of exercise. He attributed tophi, or chalk-stones, to thickness and viscidity of the humours, and the chronic or protracted forms of the disease to the admix- ture of several of these humours. 38. The doctrine of the humours, and the manner they give rise to arthritic complaints, have been fully explained by Macrobius (Satur- ! nalia, vii., 4). Mr. Adams, in the learned notes to his translation of Paulus JEuineta, remarks that the theory of the humours, notwithstand- ing its being at present in little repute, accords better with the phenomena of the disease, and is a more successful guide to practice than any hypothesis recently advanced. A similar pref- erence to it has been given by Sprengel. It should also be mentioned that the ancients, par- ticularly those just noticed, recognised the he- reditary character of the disease, and peculiar diathesis of gouty persons. The opinions of the Arabian writers are not materially different from those just stated. The most interesting production on the disease that has appeared was written by Demetrius Pepagomenos, about the middle of the 13th century, and was pub- lished at Paris in 1558. He states the remote causes of gout to be long-continued indigestion, repletion with food, drinking too much wine, venereal excesses, indolence or unaccustomed exertion, and retention of the natural secre- tions ; the venereal excesses, especially, weak- ening the tone of nervous parts. These caus- es give rise to imperfect digestion, and the ac- cumulation of excrementitious superfluities re- quiring to be evacuated from the system. When these excrementitious matters are retained, morbid humours are produced and collected in the affected joints. This very ingenious wri- ter farther remarks that, when crudities or morbid humours are formed in the system, those parts which are vigorous cast them off: but that those that are weak are unable to ac- complish this; and hence collections of such humours take place in them. 39. b. Many of the writers of the 16th, 17th, and 18th centuries were induced, by the ap- pearance of the urine, and the concretions formed in the joints, to account for the phe- nomena of the disease upon chemical princi- ples. Paracelsus first, and Hoffmann and others long afterward, ascribed the local and constitutional affections to the presence of tar« GOUT—Pathological Conditions. 49 taric salts in the blood : an opinion very gen- erally adopted until the middle of the last cen- tury. More recently, Forbes, Parkinson, Wollaston, Home, Brande, and others have endeavoured to show that there is always a redundance of uric acid in gouty persons ; and, as will be shown hereafter, there can be no doubt that the constituents of this acid exist in them in excess. But this species of change is merely one of the elements of the gouty con- dition. The connexion of the disease with plethora was very justly insisted on by Dr. Cullen; and Dr. Parry conceived that the paroxysm had a salutary influence in reducing a plethora relatively great, in restoring the balance of the circulation, and in determining the blood from internal and vital parts to the extremities. Here, again, is a part adduced for the whole of the mischief. Dr. Sutton supposed that the cause of disorder is seated in the alimentary canal; but he attempted no- thing beyond this very indefinite explanation. Broussais is more precise, if he be not more correct, in stating gout to be one of the several morbid manifestations depending upon inflam- matory action in the gastro-intestinal mucous surface. In this opinion he has been pretty closely followed by Armstrong, Mackintosh, and several writers of his own country. Dr. Bateman, Sir C. Scudamore, and Dr. Barlow have ascribed the disease to vascular plethora. Dr. Barlow, especially, insists upon its inflam- matory and plethoric nature, but pushes his doctrine too far ; while he overlooks the con- nexion of plethora with other morbid condi- tions. 40. c. It is indispensable to a correct view of the subject, to comprise all the elements forming the constitutional and local affections to which the term gout has been applied. If we analyze the numerous phenomena prece- ding, constituting, and following the disease; if we connect these with the causes most es- sential to their production, and if we refer to those agents which increase or diminish the severity of the symptoms, we must necessarily arrive at the conclusion that gout does not depend upon one morbid condition only, but upon several; that neither the superabundance of excrementitious matters in the blood, ari- sing from imperfect or effete assimilation— from the ultimate results of animalization ; nor vascular plethora, absolute or relative; nor gastro-intestinal irritation ; nor gastro-hepatic disorder, is individually sufficient to explain all the changes constituting the disease; al- though they may be sufficient, when viewed in connexion. But, even when thus considered —especially if we push the analysis sufficient- ly far—some antecedent and concomitant le- sions must be inferred. If we view the sev- eral causes in the connexion and succession in which they usually give rise to gout, we must necessarily conclude that the organic nervous energy is impaired or exhausted by them ; and that, as the organic class of nerves bestows its influence on the digestive, the secreting, and excreting functions, exhaustion of its powers will impair the functions of the organs which it supplies. The necessary consequences of such impairment will be imperfect digestion and assimilation, torpor of the liver and bow- els, impeded and disordered secretion and ex- II 7 cretion, redundancy of excrementitious matters in the circulation, and vascular plethora, arising from deficient excretion, and from a continued supply of nourishment, aided by a stimulated appetite. These may be viewed as the ele- ments of the gouty constitution or diathesis; and, when it is formed, the local action will be excited by either, or by several, of the causes mentioned above (y 35, 36). That most of these causes affect the organic nervous influ- ence more or less directly, is shown by the im- paired or otherwise disordered functions of the organs more especially endowed by this sys- tem. To functional disorder and morbid sen- sibility succeed the accumulation of effete and irritating matters in the blood, and excited vas- cular action, either local or general, or both. These matters aggravate the morbid sensibility and irritation, particularly in situations most prone, by previous disorder or debility, to ex- perience either or both. 41. It is, however, not easy to explain satis- factorily wherefore the morbid action should manifest itself in the extremities, and assume peculiar characters, otherwise than by referring both circumstances to the previous change pro- duced in the system—to the antecedent diathe- sis, either original or acquired ; and to the morbid condition of the nerves, and of the ex- halations and secretions of parts most remote from the centres of nervous power and of cir- culation. Weakness of the remote nervous ramifications will necessarily influence the cir- culation and secretions of the parts which they supply; and when the blood abounds with ex- crementitious matters, the exhaled and secre- ted fluids will necessarily possess preternatural or morbid properties, which will affect the sen- sibility of the extreme nerves, and irritate the tissues in which they are deposited. There are various phenomena, especially the sudden transition of the affection — which is some- times as quick as electricity—from one part to another, that cannot be explained otherwise than by referring them to the organic nervous system. If we consider the intimate connex- ion that exists between this system and the rest of the economy, and particularly the influ- ence which it exerts upon the vascular system, which it supplies throughout, and view both in their intimate relations with one another and with the rest of the frame—if we contemplate them as intimately interwoven together—as possessing numerous and diversified commu- nications with all the viscera and compound structures—we shall easily conceive that the altered sensibility existing in one part of this nervous circle may readily be transferred to other and distant parts, with the varying state of nervous influence, and with the several caus- es which may suppress it in its existing seat, or drive it to other organs; that a change in the state of the organic nervous influence, when preternatural or intense,, may very obviously af- fect the capillary circulation and vascular ac- tion ; and that, both nerves and capillaries be- ing thus affected, the exhalations and secre- tions of the part will be also changed, particu- larly when the fluids circulating to it are in ex- cess, or abound with excrementitious matters; the alteration of the fluids, both circulating and secreted, exalting the morbid sensibility and vascular irritability, and perpetuating the suf- 50 GOUT—Pathological Conditions. fering until the cause is removed or both con- ditions are exhausted. 42. If this view be correct, several disputed matters connected with the disease will be more readily explained. For when the predisposition or diathesis is formed, and the organic nervous influence is morbidly affected in one or several parts, and the vascular system is inordinately repleted, causes affecting either the one or the other will not infrequently transfer the morbid action from one seat to another. The local af- fection of gout being the external manifesta- tion of a constitutional disease, the suppression of it in one part will often be followed by its appearance in another ; and its spontaneous extension to a new situation will as frequently derive it from its former seat; for as long as the constitution continues in fault, nervous power being impaired, the vascular system overloaded, and the blood abounding in excre- mentitious matters, some organ must experi- ence more or less prominent disorder. This view of the nature of gout farther enables us to account for the primary seizure of an internal part or viscus; for, in proportion to the defi- ciency of nervous power, or to the abundance or vitiation of the circulating fluids, or to the weakened or congested state of some viscus, will the disposition to a misplaced or lurking form of gout exist; the vital manifestations being incapable of developing the disorder in the extremities, owing either to their impair- ment, or to the extent of the derangements just mentioned, or to both circumstances conjoined. [Dr. Prout has made it appear in the high- est degree probable that urea and lactic acid are chiefly derived from the decomposition of the gelatinous textures of the body, and lithic acid and its compounds from the albuminous princi- ples, not only of the chyle and blood, but also of the albuminous textures. He supposes, also, that when, on account of the imperfect assimi- lation of alimentary matters by the stomach and primary assimilating processes, the chylous principles are not raised to that standard of per- fection by which they are fitted to become com- ponent parts of the blood, the healthy kidney possesses the power of selecting and disorgan- izing such imperfectly developed chylous mat- ters, and of converting them into the lithate of ammonia, which he thinks is the origin of most of the common yellow amorphous sediments oc- curring to healthy individuals from slight er- rors in diet, &c. Now, as lactic acid is believ- ed by Dr. Prout to be the characteristic fea- ture in rheumatism, so also he supposes the lithic acid, developed principally during the mal- assimilation of the albuminous textures, to be the characteristic feature in gout; and that when the lactic and lithic acids are developed together, as they often are, showing that the mal-assimilation involves both the gelatinous and albuminous textures, the accompanying dis- ease partakes of a mixed character, constituting what may be properly called rheumatic gout, a form of disease which is more deep-seated and obstinate than either gout or rheumatism alone. According to these views, as he has remarked, the lactic and lithic acids, considered with ref- erence to rheumatism and gout, may be regard- ed somewhat in the light of materies morborum; or, strictly speaking, the undue presence of these acids in the urine or elsewhere, under certain circumstances, may be viewed as indi- ces of the existence of certain diseased actions going on in the primary tissues of the body, and which are known by the names of rheuma- tism and gout. If we compare the symptoms of these disea- ses with those described under the article Gt.\ s- ders, which are acknowledged to be produced by the introduction of a morbid poison into the blood, the above views of Dr. Prout will not appear altogether groundless or improbable. The early phenomena of that disease (glan- ders) closely resemble those of rheumatic gout; the pains and swellings of the large joints, with copious perspirations of offensive odour, are among the first symptoms ; and Dr. Williams records a case, admitted into St. Thomas's Hospital, of London, which was actually mis- taken for rheumatism (On Morbid Poisons). " Acute glanders in the human subject," says this writer, " is ushered in by an attack of pri- mary fever, with or without rigours. This is followed by pains in the limbs, so severe as often to be mistaken for an attack of acute rheumatism." A consideration of these and other facts has inclined us to believe that, both in gout and rheumatism, general nutrition is disturbed, not by mere local disease, nor by an impression on the nervous system, but by the development of a morbid matter in the blood, which visits every part to which that fluid is distributed, but which is attracted by some tex- tures much more than by others, but is, from unknown causes, subject to be suddenly repel- led upon other tissues, and those, too, of a more vital nature. It is also the opinion of Dr. Williams (Princi- ples of Medicine, Philad., 1844) that gout depends on the production in the system of an excess of lithic acid, which, being a highly azotized compound, is abundantly generated in those who take a large proportion of animal food, and in whom the digestive and assimilative pro- cesses are impaired. Hence it is produced by high living and sedentary habits. As it is one of the lower forms of animal matter into which the higher principles, fibrin, albumen, gelatin, &c, tend to pass in their progress towards dissolution, hence it is produced in excess where there is more azotized matter than is wanted for the reparation of the textures, or than the vital assimilating powers can appro- priate for this purpose ; but as Prout remarks, it results also from the decay of the textures, especially during febrile or inflammatory irrita- tions, during and after which copious deposites of the lithates are seen in the urine. Accord- ing to this able pathologist, the morbid effects of an excess of lithic acid will vary considera- bly, according to its amount and other circum- stances. The kidneys being the proper emunc- tories by which it is eliminated from the blood, these organs sometimes suffer from the irrita- tion which it causes ; hence nephralgia and ne- phritis may occur; or the water and alkali se- creted with it in the urine may be insufficient to hold it in solution, and it may be deposited in the form of sand or gravel, or calculus in the kidneys or bladder, and various irritations and obstructions in the urinary apparatus may be the result. " But sometimes," Dr. W. remarks, " the kidneys may fail in their power of elimi- nation ; the lithic acid and its compounds thus GOUT—Pathological Conditions. 51 accumulate in the blood, and may cause va- rious irritations and functional derangements (irregular gout), until at length some circum- stance fixes the irritation on a limb, and a fit of regular gout is the consequence. In this fit, if perfect, inflammation is exerted with more or less febrile disturbance, which subsides as a copious deposite takes place in the urine, show- ing the removal of the morbid matter. The more acute and fixed the inflammation, and the smarter the fever, the more abundant is the de- posite, and the more free is the patient from disease afterward. On the other hand, when the inflammation is low, changing its place, and with little fever, it generally tarries long, and the system is not relieved. It is when gout thus lasts long, or frequently recurs, that often its material so accumulates in the joints as to be deposited in the form of a plastery or calculous matter, consisting of lithate of soda (chalk-stones of gout). This chronic form of gout is connect- ed with a more or less permanent disorder of the digestive or assimilative functions, which renders its treatment more difficult or less successful than that of the more acute forms of gout. In such cases (chronic) lithic acid seems to be engendered in great abundance, being often thrown off in large quantities in the urine for an indefinite period, yet never leaving the body free. Such cases are commonly ei- ther hereditary, or those which have been ren- dered inveterate by intemperate habits or neg- lect of proper treatment."*—(Loc. cit.) The hypothesis that gout is caused by the presence of lithic acid in the blood, was pro- posed near the end of the last century by Mr. Murray Forbes, who supposed that this agent was prone to become deposited in the small vessels of tendons, ligaments, &c, under the influence of some stronger acid, either taken into the stomach or formed in the process of digestion. Dr. Todd, however, who admits that the same causes which favour the devel- opment of the lithic acid diathesis will promote the gouty one—that indolence, good living, want of exercise, deficient cutaneous action, are equally favourable to the production of both states of constitution; and that the lithic acid diathesis is that which passes most readily into * [According to Liebig, whose theory is advocated by Dr. Hence Jones, the presence of lithic acid in the sys- tem is due to the deficiency of oxygen; and in the natural state, under the influence of a due supply of oxygen, this substance nearly or altogether disappears, being decompo- sed by oxygen into urea and carbonic acid ; so that in healthy urine its quantity is very small, and in the carniv- orous animals, which are largely supplied with oxygen, it disappears altogether. He supposes the free acid, which mists in the system, to be lactic acid derived from the stomach, and that this and other non-nitrogenous compounds present in the blood attract the oxygen, and hinder its ac- tion upon the lithic acid. (Lithic acid, Liebio believes, is formed from blood or muscular fibre by the action of ox- ygen and water; for, he says, the elements of lithate of ammonia and of choleic acid, with one equivalent of water and one of oxygen, make up the formula of blood.) For objections to this theory, the reader may consult Todd, " On Gout and Rheumatic Fever," p. 69. The British and For. Med. Review (vol. xvi.) suggests that lithate of soda is the morbific agent, because this sub- stance is separated from the blood in gouty deposites, from the known connexion of gout with biliary as well as urina- ry derangements, and from the beneficial results of treat- ment directed to both these secretions. " Under the influ- ence of particular substances," it remarks, " lithic acid has • tendency to accumulate in the blood ; and it seems to us ?uite possible that, so long as it retains its uncombined orm, gwtt may not result; but if, by a deficiency in the se- cretion of bile, soda also be allowed to accumulate, the two will combine, and lithate of soda will be formed."] the gouty—nevertheless is of opinion that the presence of an undue quantity of lithic acid in the system, even although accompanied with the formation of a free acid, is not sufficient to account for the formation of gout, as we meet with many instances in which these conditions are present, even for a considerable period, without giving rise to any of the symptoms of gout. Brickdust sediments, he remarks, are among the most common of those that are found in the urine : " a slight disturbance of the di- gestive process, or a febrile cold, will increase the quantity of lithic acid; in young persons such sediments are very common ; in fevers they appear, at first, in the urine, then disappear, and their reappearance sometimes seems criti- cal. In none of these cases do symptoms of gout occur, even when the disposition to the deposite is of long duration. I have known these deposites to show themselves for weeks and months without producing any symptom of gout. In hysterical women, the lithates and lithic acid are deposited in large quantity; and in diseases of the liver, chronic as well as acute, the proportion of this acid is very much augmented." According to this writer, an ad- equate theory of gout should explain, 1. The frequent accompaniment of a large quantity of lithic acid with the disease ; 2. The occasional occurrence of gout, when this acid cannot be formed in undue quantity, as in the cases of gout appearing in low states of the system ; 3. It must account for the formation of a large quan- tity of free acid in the system, as appears from the undue acidity of the digestive organs and the sweat; and, lastly, it must explain the pa- thognomonic character of the disease, namely, the formation of lithate of soda in various parts of the body. In the present state of our knowl- edge, Dr. T. thinks it impossible to determine the correct theory of gout; but that it appears highly probable that the gouty matter is, in the first instance, derived from the stomach or du- odenum, inasmuch as a disturbance of the func- tions of those parts is an invariable antecedent or accompaniment of the fit; and as such de- rangements are generally accompanied with an undue development of lactic acid, he deems it fair to conclude that it may be the primary dis- turbing agent. If the views of this writer are to be received, we are then to believe that the matter of gout is a compound, derived from a product of unhealthy action of the stomach and duodenum, which being absorbed into the blood, unites there with some element of the bile which has been suffered to accumulate through the defective secretory action of the liver. " As the same causes which induce these two states will give rise to a lithic acid diathesis, we find it usually associated with them. But the former may exist without the latter ; and therefore gout may show itself without the oc- currence, at the same time, of a preternatural quantity of lithic acid." Such an organic com- pound, he believes, may exist in the blood in variable quantity, and for an indefinite period, contaminating the whole frame, as well as the offspring, and thus give rise to the gouty diath- esis ; or this matter, ever present in the sys- tem, may be liable to periodical accumulations, which can only be got rid of by periodical par- oxysms. Our countryman, Dr. Rush, has furnished 52 GOUT—Treatment. some able observations on this disease, char- acterized by the same boldness and originality of views as distinguish all his medical essays (Med. Inq., vol. ii., p. 247). Defining it to be a disease of the whole system, affecting the ligaments, blood-vessels, stomach, bowels, brain, liver, lymphatics, nerves, muscles, car- tilages, bones, and skin, he, nevertheless, held that it was a primary disease only of the solids ; chalk-stones, dropsical effusions, &c, being only the effects of a morbid action in the blood- vessels, as maintained by Cullen. The re- mote and exciting causes of the disease, which are pointed out with great minuteness by him, do not differ essentially from those given by Copland ; he, however, supposes that females are quite as subject to gout, though not in the extremities, as males, and that tea is a power- ful predisposing cause. He speaks of having treated it in the native American Indian, and of its occurring occasionally among those who make no use of fermented or distilled liquors. Its hereditary character he held to depend upon the propagation of a similar temperament from father to son, which sometimes passes over one generation to appear in the next. In ev- ery instance he believed it to be induced by general predisposing debility, which may have been occasioned by indolence, great bodily la- bour, intemperance in eating, excessive venery, acid aliments and drinks, strong tea and coffee, fermented and distilled liquors, grief, anxiety, and other depressing mental emotions, &c. That form of gout which appears in the liga- ments and muscles, he supposed is always brought on by the use of spirituous drinks ; and whatever form the disease assumed, he be- lieved it to consist simply in morbid excitement accompanied with irregular action, or the ab- sence of all action, from the force of stimulus, precisely as occurs in fevers. The doctrine of a specific acrimony, or morbid poison, he re- jected as unphilosophical and improbable. This was in accordance with his general theory of disease, namely, that however varied morbid actions may be by their causes, seats, and ef- fects, they are all of precisely the same nature. According to this writer, there is not a disease in the whole catalogue of nosology but what is mimicked by the gout, its symptoms being man- ifested in the ligaments, the blood-vessels, the viscera, the nervous system, the alimentary canal, the lymphatics, the skin, and the bones ; in short, "it is an epitome of all diseases." Instead, therefore, of being a primary affection of the joints, Dr. Rush understood by the name, gout, a disease consisting simply in morbid ex- citement, invited by debility, and disposed to invade every organ and tissue of the body.— (See Loc. cit.)} 43. VI. Treatment. — i. The opinions of the ancients, as to the treatment of gout, are in many respects as deserving of notice as those of modern writers ; indeed, there is little dif- ference between the views of some of the former on this subject and those of the latter. As at the present day, so in ancient times were cold applications to the part, and colchi- cum internally, advised by some and condemn- ed by others; so also, as may be seen from the Tragopodagra ascribed to Lucian, were nu- merous nostrums lauded for the complaint, as well as a rational treatment pursued by the regular practitioners of physie ; and so also, as at the present day, the habits and irregularities of the patient brought discredit on the science of the physician, and led to the too general adoption of the opinion of Ovid, that '• Tollcre nodosam nescit medicina podagram." 44. Hippocrates recommended purgatives by the mouth and by injection, and cooling ap- plications to the part. In the more chronic cases, he advised means similar to the moxa of the Japanese. Celsus also prescribed re- frigerant applications to the affected part; but he likewise had recourse to warm fomentations conjoined with anodynes, and to depletions. Aret^eus seems to have trusted chiefly to hel- lebore, and to applications of wool moistened with various substances, as oil, oxycrate, &c. Galen commenced the treatment of gout by evacuating offending matters by bleeding and purging; he afterward had recourse to discu- tient applications. C.klius Aurelianus direct- ed blood to be abstracted from the part by scarifications, and sponges squeezed out of hot water, or oil and water, or a decoction of fenu- greek, to be afterward applied. He also pre- scribed gentle emetics and aperient clysters. He disapproved of burning the parts, and of the indiscriminate use of narcotics; but advised warm bathing, spare diet, emollient ointments, and afterward gentle exercise. He enjoined complete abstinence from the commencement of the attack ; and at its decline he prescribed a medicine nearly the same as the Portland powder. Oribasius confided chiefly in bleed- ing and purging, especially in plethoric persons, and in the spring. Aetius evacuated redun- dant humours by these means, and afterward endeavoured to strengthen the parts. 45. Alexander Trallianus adopted a treat- ment which he viewed as appropriate to his pathology of the disease. In cases proceeding from a bilious humour, as indicated by burning heat and the absence of swelling, he prescribed chologogue purgatives, consisting chiefly of cathartics and bitters conjoined, and cooling anodyne applications to the affected parts, with spare diet. When occasioned by a phlegmatic humour, indicated by the absence of heat and redness, he considered calefacients to be bene- ficial, and refrigerants injurious, and recom- mended a combination of purgatives and atten- uants, as hellebore, thyme, cumin, &c. Af- ter purging, he directed warm attenuants in- ternally, and calefacient anodyne cataplasms to the external affection. When there was gen- eral fulness of blood, or determination to the affected joint, he advised blood-letting, and ab- stinence from wine and animal food, and dis- cutients to the part. He has remarked that some insist upon taking medicines to allay at once the violence of their pains, not choosing to submit to a methodical treatment, but that he does not approve of this practice. For this purpose, he adds, the hermodactylus is particu- larly trusted to ; and he admits that it seldom fails to remove a paroxysm ; but he also affirms that it occasions more frequent returns of it The identity of hermodactylus and colchicum is highly probable, as maintained by Prosper Alpinus, Sir H. Halford, and others. Alex- ander has farther stated that some endeavour to correct the prejudicial effects of this medi- cine by adding to it cumin, mastic, or ginger GOUT—Treatment. 53 thinking that its action is narcotic; but this he affirms to be a mistake, for in that case it could not prove cathartic. He admits, however, that these things may correct its bad effects upon the stomach; and he therefore prescribes a combination of the hermodactylus with aniseed, pepper, and myrrh, or with aloes, scammony, elaterium, colocynth, &c. He preferred, how- ever, the coronopodium (which Mr. Adams, in his learned commentaries on Paulus, believes to be the buckthorn plantain, or plantagocoronopus), as it procures evacuations and relief from pain without injuring the stomach. 46 Paulus J^gineta advised a nearly simi- lar method to that adopted by Alexander. He employed chologogue purgatives for the evacu- ation of bilious humours, when he inferred gout to arise from this cause; and numerous cool- ing and anodyne cataplasms to the affected part, with a refrigerant and diluent diet, avoid- ing repletion and the use of heating dishes or liquors, as well as mental emotions and vene- real indulgences. In the sanguineous form of the disease, and in the first attacks, he en- joined blood-letting and purgatives ; the latter consisting chiefly of a combination of colocynth, aloes, black hellebore, and scammony. Some, he has remarked, have recourse to purging with hermodactylus ; but it is bad for the stomach, producing nausea and anorexia, although it re- moves the disease very speedily. In gout from a mixture of humours, he also had recourse to depletions in early attacks ; but, after frequent seizures, he considered the loss of blood inju- rious. Besides these, he directed a variety of both internal and external means, many of which deserve adoption, and are similar to those hereafter to be noticed. With respect to prophylaxis, he advised a moderate use of wine, exercise, and frictions of the joints, morning and evening, with oil triturated with salt. 47. The opinions of the Arabian physicians differ not materially from those of the Greeks. Serapion, Avicenna, and Rhases recommend- ed evacuations and the hermodactylus. Haly Abbas directed blood-letting in cases proceed- ing from sanguineous plethora, and used cool- ing applications to the joints. For the bilious defluxion, he prescribed emetics and drastic purgatives, consisting of scammony, aloes, col- ocynth, and hermodactylus; and, for the serous or phlegmatic defluxion, very nearly the same means, the local applications being varied. The treatment adopted by Alsaharavius was almost identical with that pursued by Alexan- der, Paulus, and Haly Abbas. 48. Demetrius Pepagomenos has justly re- marked that the prophylaxis of gout is easily prescribed, but followed with great difficulty. It consists in great moderation in eating and drinking, and in avoiding indigestion. Viewing the disease as one of repletion, he ordered evacuations for its cure, consisting of emetics, blood-letting, and purgatives, and with a very judicious reference to the form and stage of the disease. He forbade the use of strong emetics ; but vomiting by gentle means he had recourse to at the commencement. In early attacks, and at their beginning, when there was evidence of plethora, he prescribed blood- letting ; but he considered it prejudicial in other circumstances, or much inferior to active pur- ging. He was favourable to the use of hermo- dactylus as a purgative, and combined it with aromatics. In other respects his treatment was similar to that of Alexander. 49. The reader will observe, from what has been just stated, how little has been added to our knowledge of thi3 subject by the numerous productions that have appeared since the revi- val of learning in Europe; and that, although there is much that is trifling, a little that is ab- surd, and something that is questionable in the doctrines and treatment of gout adopted by the ancients, there is also much deserving of com- mendation and adoption. 50. ii. Treatment of Acute Gout.—The indi- cations are, 1st. To avert a threatened attack; 2d. To alleviate the symptoms during the par- oxysm ; and, 3d. To prevent the return of the disease, by suitable regimen and medical treat- ment, after the paroxysm has ceased. —A. In order to avert, or to render more mild a threat- ened attack, the premonitory symptoms should be treated promptly and judiciously. Much suffering and injury to the constitution have arisen from the idea that the paroxysm is a salutary effort of nature, and that the preven- tion of it may be followed by serious conse- quences. There is, however, some truth in the opinion, for, as I have shown, the external af- fection being the outward manifestation of con- stitutional disease, the suppression or preven- tion of it in an external part may lead to results still more severe than the impending attack. But it is the suppression of the paroxysm by means which leave the constitutional disorders untouched, or which increase them, that is in- jurious, and not the prevention of it by reme- dies directed to the removal of these internal disorders themselves in which the attack ori- ginates. A large dose of an aero-narcotic, as of colchicum, veratrum, or veratria, aconitum, &c, has often the effect of suppressing the morbid sensibility, and with it the irritative vascular action of the seizure ; and thus frees the patient from the impending suffering for a time. But it leaves the internal disorders, of which the external is merely a part, in the same state as before, or even increases them ; inasmuch as it tends to weaken organic ner- vous power, to irritate the digestive mucous surface, and to impair the functions of excre- tion ; and the consequence is, either a more frequent return of the precursory symptoms of the attack, or the supervention of some serious visceral disease. The means, therefore, to be had recourse to, in order to avert the paroxysm, should be those only which are calculated to remove the internal derangements, in which it originates. These derangements we have seen to be, weakened organic nervous power; a torpid state of the functions of the liver, with accumulations of bile in the biliary passages and liver ; congestion of this viscus ; faecal ac- cumulations in the large bowels ; collections of mucous sordes on the digestive mucous sur- face ; vascular erethism, or inflammatory irri- tation of the surface; and the superabundance of excrementitious matters in the circulation. Means, therefore, which will remove these conditions, and prevent their recurrence, will the most effectually avert both a threatened paroxysm and a return of the disease. 51. Guided by those views, general blood-let- 54 GOUT—Treatment ok Acute. ting may be. employed in robust and plethoric persons. If signs of congestion of the head or of the liver be present, or of inflammatory ir- ritation of the digestive mucous surface, local depletions may be substituted, or used in addi- tion to the general evacuation. The quantity of blood taken away should depend upon the age and strength of the patient, and other cir- cumstances of the case. Haemorrhoidal or other spontaneous evacuations ought to be en- couraged by aloetic purgatives, &c. If the tongue be much loaded, and if heartburn, acrid eructations, or nausea be complained of, nei- ther pain nor tenderness of the epigastrium be- ing present, an emetic will generally be of ser- vice. But if vascular depletion be indicated, it should be premised. Emetics have been rec- ommended by Celsus, Fabricius, Hildanus, Gesner, Stoll, Scudamore, and others; they will be found most serviceable as here advised; in other circumstances they are doubtful means, and require much discrimination. If indigesti- ble matters remain in the stomach, emetics should not be withheld •, but when there are pain and tenderness at the epigastrium, with determination to the head, they may be inju- rious. In almost every case, purgatives should be prescribed, although the bowels may have been said to be regular or open ; for collections of morbid secretions in the biliary organs, and of faecal matters in the cells of the colon, may nevertheless exist. Therefore a full dose of calomel, with camphor or with James's powder, or with both, may be given at bedtime, and a stomachic purgative the following morning. The draught here prescribed I have found most efficient, especially when the bowels are very sluggish; and the frequent repetition of it is attended by no disadvantage: No. 233. R Infus. Gentians Comp., Infus. Senna? Comp., aa Jj.; Magnes. Sulphatis 3jss. (vel Sods carbon. 3j.); Tinct. Cardamom. Co. et Tinct. Senme Comp. aa 3jss. M. Fiat Haustus, quamprimum mane sumendus. 52. If the excretions continue to present or assume morbid appearances, a small dose of blue pill, or of hydrargyrum cum creta with soap, or a full dose of calcined magnesia, should be taken at bedtime, and the above draught in the morning, until they assume a natural char- acter. If the precursory symptoms continue nevertheless, I agree with Sir C. Scudamore in considering that the constitution is labouring under the causes of the paroxysm, almost as much as if the attack had been developed, and that the treatment required during the parox- ysm should be resorted to. If the means here recommended restore the functions to a healthy state, abstinence or moderation in diet, regular exercise, especially on horseback, mental quie- tude, and early hours, should be strictly ob- served. 53. B. The Treatment of the Paroxysm should be varied according to the age, strength, and habit of body of the patient, to the predisposing and exciting causes, to the duration and char- acters of the paroxysm, and to the frequency and severity of the previous seizures.—a. Blood- letting is required in the plethoric and robust, and in early attacks, when the constitution is unbroken, and the inflammatory diathesis evi- dently exists. In these circumstances, it has been advised by Celsus, Galen, Alexander, Horstius, Riverius, Jumelin, Le Tellier, Sydenham, Patten, Huxham. Cullen, Hosack, Musorave, Macbride, De Vernevil, Heber- den, Scudamore, &c. It has been too strong- ly insisted upon by Hamilton, Rush, and Bah- low, while it has been considered injurious by Trampel, Barthez, Halle, and Guilbert, un- less when the inflammatory action is very manifestly developed in some internal organ; or in strong plethoric persons, when the gen- eral vascular excitement is very great. The practitioner should be guided as to the extent of the depletion by the circumstances above alluded to; keeping in view the fact that the disease is one more of irritation than of inflam- mation ; that the vascular excitement is, in great measure, the consequence of the morbid sensibility, and will subside as it is subdued. Local depletions are often preferable to general blood-letting, particularly when tenderness or fulness of the epigastrium or hypochondiia is present, and will generally be sufficient to re- move hepatic congestion and vascular excite- ment of the gastro-enteric mucous surface. When blood-letting is clearly indicated, it should not be delayed, as the benefit it is cal- culated to afford will be diminished very mate- rially by delay, the debility consequent upon unmitigated irritation rendering the deferred depletion of little or no avail.* 54. b. Alvine evacuations are of less doubtful efficacy even than vascular depletion. Emetics are sometimes of service at the commence- ment of the paroxysm, when the symptoms in- dicating (v 51) the propriety of resorting to them are present. In some cases they miti- gate the attack, while in others they have little or no effect upon it. They ought to be em- ployed with caution. When the case requires both vascular depletions and an emetic, the latter ought not to be exhibited until the for- mer has been carried into effect. Purgatives are of the most unequivocal benefit. Many of the empirical remedies employed against the disease are serviceable only in as far as they increase the alvine excretions. As vascular congestion of the liver and accumulations of * [We have found mild antiphlogistic measures general- ly sufficient to relieve gouty attacks, and blood-letting rare- ly required unless in a very plethoric state of the system, and when the fever is high : we should bear in mind that there is danger in carrying this remedy too far, from its tendency to prevent a crisis. Local blood-letting will rare- ly be called for, as the inflammation will, in a large major- ity of cases, speedily subside, by keeping "he part warm and still; by covering it with cotton, wool, or oiled silk; or by the application of soothing lotions. As a general rule, we are satisfied, from considerable experience, that the an- tiphlogistic treatment of gout should be of the mild kind, as purgatives, calomel, or blue pill, combined with antimony or saline medicines ; but no permanent relief will take place until the urinary deposites commence. Venesection we hold to be admissible but in certain.cases, and under the circum- stances pointed out by our author. Dr. Barlow, of Bath, England, referring to the states of the system under which gout is developed, maintains the existence of three kinds of plethora, one in which the nutritious function is redun- dant without much affecting the self-adjusting powers of the system, or without much diminution of the excreting functions ; the second, with some diminution of the excre- ting functions taking place, chiefly in constitutions deficient in natural vigour, or impaired by predisposition to disease ; and the third, with impaired action of the excreting func- tions, indicated by sallow, dmgy completion, harih, dry skin, s ow, inert, and constipated bowels, and hiff£cok»?. ed foetid urine. According to Dr. B., acute or regular gout occurs in connexion with one or other of the first two forms of plethora, and these cannot be satisfactorily or ef- fectually removed without the employment of bio, ™(eu[ne • he, accordingly, recommends that e/acuat.on, both «iSLi and local, especially ,n young persons or thoae of *£%& age, and of average vigour of constitution.] "uwim GOUT—Treatment of Acute. 56 bile in the biliary passages are often connected with the production of the fit, such purgatives as promote the circulation in this organ, and increase its excreting function, should be se- lected. With this view, from five to ten grains of calomel, with four or five of James's powder, may be given at bedtime, and the draught pre- scribed above (y 51) early on the following morning If these do not act in the course of a few hours, a dose of magnesia, and of sul- phate of magnesia in any aromatic water, may be taken, and repeated until the bowels are freely opened. Purgatives were actively em- ployed in gout by the ancients, veratrum and hermodactylus having been chiefly used with this intention. Rhazes advised a cathartic to be repeated eight times. Riverius, Riedlin, Thilenius, Cadogan, and most English writers, have recommended them. Schroxder prefer- red the preparations of rhubarb; and these, conjoined with magnesia, or any of the other purgatives in common use, may be prescribed. Sir C. Scudamore prescribed the colchicum in the first aperient draught, giving from one to two drachms of the acetic preparation, neutral- ized by magnesia, and conjoined with the sul- phate of magnesia. This medicine he repeats at intervals of four, six, or eight hours, accord- ing to its action and the urgency of the symp- toms.* Although this is armong the mildest of the preparations of colchicum, especially when its acetic acid is neutralized by magnesia, yet I have seen it, in this dose, productive of se- rious effects ; and it is more likely to be inju- rious when it fails in acting upon the bowels ; for in this case its influence is exerted upon the nervous system, and not upon the excreting functions, the morbid sensibility being partially suppressed by it, but the source of disorder re- maining untouched. The consequences are, either a frequent return of the fits, or a contin- uance of the internal affections in aggravated forms, or the supervention of some one of the irregular states of the disease. Where biliary accumulation or congestion of the liver exists, a large dose of colchicum, unless conjoined with an active stomachic purgative, may, in the early stage of the paroxysm, so suddenly suppress it as to give rise to the serious affec- tions alluded to under the head of retrocedent and misplaced gout (v 18, 21). This is no sup- posititious case, for two such instances have fallen within my own observation, one of which has been already adverted to (v 19). 55. In early fits of the disease, when much inflammatory excitement exists, colchicum may be conjoined with the cooling saline purgatives and with magnesia, as Sir C. Scudamore advi- ses ; but the dose should be much less than just mentioned, and ought seldom to exceed half a drachm of any of the fluid preparations ; and it should not be given more frequently than thrice in the day, until the effects are observed, as even in this quantity I have seen it have, in some constitutions, a very remarkable seda- * [" Scudamore's Mixture" is prepared as follows: R Mag. Sulphat. 5i.-?ij. ; Sodar. in Aqua Mentha f. f x. ; adde Acet. Colchici f. Ji.-fiss. ; Sirup Croci f. Ji.; Mag- nesia 3viij. Mix. Dose, three table-spoonsful every six hours till free evacuations are produced. Dr. Macintosh recommends a saturated solution of the seeds in wine, in doses of from 20 to 120 drops, conjoined either with the same quantity of Tinct. Hyoscyamus, or with a half or third part of the sedative solution of opium. J tive influence, producing even serious symp- toms. In several persons, and three of these members of the profession, I have observed that even twenty drops of the mildest prepara- tions of colchicum could not be taken without most distressing internal irritation, and a sense of sinking being produced. This effect still more frequently occurs in the atonic or chronic states of the disease. Therefore, when the pa- tient is either advanced in life, or has suffered repeated attacks, or is possessed of weak con- stitutional power, the combination of colchicum with antacids, and warm stomachics, or the tinct. colchici compos., will be most appropri- ate ; and either the infusion of senna or of rhubarb, or the decoction of aloes, may be added to them in such quantity as may be re- quired to operate freely on the bowels. No. 234. R Infusi Caryophylor., Infusi Senna? Comp.,ftS 3vj. ; Magnes. Calcinate 3j. ; Vini Colchici Hlxxv. (vel Aceti Colchici 3ss.) ; Spiritus Pimentoe 3ss. M. Fiat Haustus, ter in die sumendus. No. 235. Infusi Aurantior. Comp., Infusi Rhei, 5a 3»j.; Magnes. Carbon. 3j. ; Tinct. Colchici 3ss. (vel Tinct. Colchici Comp. Tfl,xxxv ); Tinct. Cardamom. Comp. 3j.; M. Fiat Haustus, sexta quaque hora sumendus. No. 236, Decocti Aloe's Comp. Jvij. ; Aqua Menth. Virid. 3ivss. ; Tinct. Colchici 3ss. ; Spirit. Ammoniae Arom. 3j. M. Fiat Haustus. No. 237. Soda; Carbon. 3ss.; Vini Colchici (vel Tinct. Colchici Comp.) 3ss. ; Infusi Sennae Comp., Infusi Aurant. Comp., aa 3vj.; Tinct. Lavand. Comp. 3j. M. Fiat Haus- tus. 56. It will often be necessary, especially when the countenance is sallow or bilious, the hypochondria and epigastrium full, or tender on pressure, to exhibit on alternate nights, or even every night, a dose of calomel, or of blue pill, with James's powder. But care should be taken that the mercury does not produce its specific action, which very generally will be prevented by the active exhibition of the pur- gatives just mentioned. Where much febrile excitement exists, James's powder, or some other antimonial, with or without an anodyne, according to circumstances, should be prescri- bed ; and if nervous power be much reduced, two or three grains of camphor may be either substituted for these, or conjoined with them. The colchicum may be given in the form of pill, the powder being combined with camphor and the watery extract of aloes, or the aloes and myrrh pill, three or four doses being taken in the twenty-four hours, and as much of the purgative as will operate sufficiently on the bowels. The action of colchicum is exerted chiefly on the digestive mucous surface and liver, the secreting functions of which it mani- festly augments. When it does not pass quick- ly off by the bowels it is partially absorbed, and increases the functions of the kidneys. It was employed by the ancients, and physicians of the middle ages, and entered into the compo- sition of most of the gout specifics of every epoch. Stoerck introduced it into regular practice in modern times, and used it chiefly as a diuretic. Mr. Want brought it into use in 1815 as a cure for gout. Since then it has been very generally, and but too often inju- diciously employed in this and in other diseases. [Dr. Williams supposes that the efficacy of colchicum depends more on its purgative than its diuretic effects; but we find it increase, in a very notable manner, the quantity of lithic acid and urea in the urine, as well as its other solid contents. This we hold to be the great 56 GOUT—Treatment op Acute. object in the treatment of gout, and the colchi- cum is to be given in such quantities as the stomach will bear, taking great care not to cause nausea or diarrhoea. It should be given with alkalies, or carbonated alkalies, to help carry off the lithic acid. We have found the wine of the root or the seeds, freshly prepared, the best form of administration, always combi- ning it with some alkali. If much fever is present, it should be given with salines or an- timonials ; if there is acidity and flatulence, with magnesia ; and if the bowels are torpid, with the sulphate of magnesia. If there is much nervous irritation, a full dose of Dover's powder should also be given.] 57. Cathartics are not equally suited to all cases. Where the bowels are very torpid, the liver congested, and the tongue loaded, they (see Appendix, F. 181, 266, 378, 430) are ne- cessary, and it is chiefly by them that we can remove the excrementitious matters abounding in the circulation. But in other instances, particularly when these disorders do not exist, or when the bowels are easily relaxed, or are irritable, and when the patient is nervous and debilitated, aperients or laxatives, and saline medicines with the alkali in excess, or calcined magnesia with or without colchicum, will be more serviceable than active purgatives, un- less conjoined with tonics, aromatics, or stim- ulants. Neutral salts, taken so as to act gen- tly upon the bowels, have generally also a refrigerant effect; and, being partially absorbed, exert a beneficial influence on the circulation and functions of the kidneys. When the saline medicine is conjoined with an alkali or with magnesia, these effects are still more manifest, and not only are the intestinal discharges in- creased, but the urine is rendered more copi- ous and natural. Colchicum, judiciously com- bined with these, will often allay pain, bring down the pulse, and promote the secretions from the liver and kidneys; but if it occasion depression or nausea, it should be discontinued. Although purgatives are unequivocally bene- ficial when employed as here advised, yet Syd- enham, Warner, and most French writers have condemned the use of them in this dis- ease. Even Heberden does not appear favour- able to them. This, however, evidently has arisen from either an injudicious use of them, or inappropriate modes of exhibiting them. 57.* Diuretics are beneficial in this disease, in as far as they promote the removal of excre- mentitious matters from the circulation. The saline substances already alluded to, and the alkalies, are, upon the whole, the most prefer- able of this class of medicines. Of the former, the citrates of potash and of soda, the acetate of potash, and the sulphates of soda and mag- nesia, are to be preferred ; and of the latter, the fixed alkalies and magnesia. M. Mazuyer recommends potash and its acetate, from an opinion that the presence of uric acid in the blood is a principal cause of the disease. Al- kalies in various forms have been long recom- mended in gout. In the form of soap, they have been prescribed by Boerhaave and Whytt. Their carbonates were used by Tozzi, Quarin, Blane, Gardner, Wollaston, and others. The alkaline earths have, however, been preferred : by several writers, especially when acidity of the prima via existed. Whytt and Blane were favourable to lime-water, and to preparations of chalk, in these circumstances. Magnesia, both calcined and carbonated, has been ireneral ly employed, and is preferable, upon the whole, to any other absorbent, inasmuch as it acts gently upon the bowels and kidneys, without weakening the digestive mucous surface. Its effects in removing the morbid state of the urine in gouty subjects, which have been so well described by Dr. Prout, and noticed above (76.—T. Mayerne, Treatise on the Gout, from th« French, by T. Shirley. l2ino. Lond., 1676.—Riedlin, Millenanus, n. 284.—Ruland, Cur. Empir., vol. ii.—J. B. Contuli, De Lapidibus Podagra; et Chiragne in Corpore ilumano produc- es, 4to. Rom., 1679.—Sydenham, Tr. de P-xlagra, v. Opus- cuL, p. 541.—T. Ghyles. Treatise of the Joint Sickness or Gout, 12mo. Lond., 1684.—/. Floyer, Appendix to Preter- natural State of Animal Tumours, &c, 8vo. Lond., 1686.— Thevenot, Voyages, vol. i., c. 27.—J. Greenfield, or Groen- velt, Arlhritology, or a Discourse of the Gout, Svo. Lond., 1691.—W. Atkins, A Discourse showing the Nature of the Gout, 12mo. Lond., 1694.—Le Conte, Nouvellcs Memoires sur l'Etat present de la Chine, 12mo. Paris, 1696.—Werl- hof, Opp., iii., p. 700.— Colbatch, Physico-Medical Essays, 8vo. London, 1696 ; Treatise of the Gout, Svo. London, 1697.—Hoffmann, Dissertatio de Reinedio Doloris Podagrici genuino et simplicissimo. Halae, 1697 ; Dissertatio de Po- dagra Retrocedenle in Corpus. Halae, 1700.—Boerhaave, Prax. Med., vol. v., p. 193.— W. Musgrave, De Arthritide Auomala, 8vo. Oxon., 1709; De Arthritide Symtoinalica. Oxford, 1703.—Stahl, De Nova Podagrae Pathologia. Halai, 1704.—Baglivi, De Pr. Med., i., cap. 9; ii., cap. 6, 7.—J. Martin, The Attila of the Gout, Svo. Lond., 1713.—R. Boulton, Treatise on Gout, King's Evil, 21.—J. A. Helvetius, Traite des Pertes du Sang. Paris, 1697 ; Diss, sur les bons Effets de I'Alum, 12ino. Par., 1704.—Stahl, Dissert, de Mensium Viis insolitis, 4to. Halae, 1702; Programma de Consult. Utilit. Haemorrhagiarum, 4to, 1704.— Friend. Histnria Med- icines, p. 320.—Peril, Me moire de l'Academie do Cliirurgie, t. i., p. 237.—M. Alberti. Diss. Pathol. Haemorrhagiarum, 4to. Halae, 1704 ; De Hiemorr. Criticis, 4to. Halae, 1710; De Adstring. Pervers. Usu in Haemnrrhaciis, 4to. Halae, 1729 ; De Hiemnrrhagiarum Statu Pneternat., 4to. Halae, 1735 ; De Haemorr. Complicatione, 4to. Halae, 1752.—J. Juncker, Dissert, de Motuum Augmento post Haemorrh. tarn Naturab. quam Artific. saep. observando, 4to. liaise, 1734; De Haemorr. Natural generatim consul., 4to. Halae, 1739 ; De Quadrup. Haemorrh. Natural, respectu, 4to. Halae, 1746.—Baglivi, Op., 4to, p. 86.—Schurig, Haemato- logia, p. 234-313.—Morgagni. De Sed. el Caus. Morborum, ep. ix., art. 4 ; ep. xvii., art. 17 ; ep. xxi., art. 17 ; ep. xxi., art. 14, 47 ; ep. Iii., art. 34 ; ep. liii., art. 3, 5 ; ep. liv., art. 10.—Schwarzmann, Pr. de Hu-morrhagiis Nuturalibtu et Morbis cum iis cohaereulibus. Ma?unt., 1742.—Heben- streit, Pr. Spec, xvii., de Haemorrhagiis Criticis. Lips., 1749.—Blankard, Collect. Med. Phys., cent, i., n. 40.—Bar- tholinus. Hist. Anat., cent, v., hist. 97.—Parker, The Lig- ature preferable to Agaric. Lond., 1755.—Lentin, Bey- trftge, b. iv., p. 171 —Baden, Observ., No. l.—Plenciz, Acta et Observ. Med., p. 162.— White, Of the Topical Applica- tion of the Sponge in the Stoppage of Haemorrhages, 8vo. Lond., 1762.—Car. de Olnhausen, De Usu Vitrioli Ferri ad- versus Haemorrhagias, Svo. Tubingae, 1763.—Ludwig, Pr. de nimiis Haemorrhagiis Causa Debilitatis in Morbis. Lips., 1763.—Young, On Opium, cap. 14, 15,17.—Stoll, Rat. Med., vol. vii., p. 96.—Hewson, Fhilos. Transact., vol. Ix.—Gmclin, Dissert, de probato tutoque Usu interno Vitrioli Ferri fac- titii adversus Haemorrh. Spontan.larg.,4to. Tubing.. 1763. —Xi. Tessari, Sanguinis Fluxus multiplex, 8vo. Venet., 1765.— Yalhsneri, Opp., iii., p. 305.—Bisset. Medical Es- says and Observations, 8vo. Lond., 1766.—Hasenohrl, His- tor. Febr. Petech.. p. 60.—De Haen, Rat. Med., part x., c. 6, t) 5.—V. A. Koster, Verhandeling over de Bloedstorting, Svo. Leid., 1768.—Af. Griffith, Practical Observations ou Hectic Fevers and Haemorrhage, Svo. Loud., 1776.—Stex- dele, Abhandl. von Blutniissen. Wien., 1776.—K. C. Krause, De Haemorrhagiarum Pathol., 8vo. Lips., 1777.—J. C. A. Mayer, Usus Aquae Frigidus in sistemlis Haemorrhagiis. Francf., 1783.—K. C. Krause, Abhandlung von den Blut- fliissen, Svo. Leips., 1783.—H. R. Reynolds, On the Use of Lead in Haemorrhage, Svo. Lond., 17S5.— Neumann, Beytrage zur Arzneywissenschaft, cap. i.— Henmng, Bey- trSge zur Practischen Arzneykuude, 1 th.—F. Home, Clin. Experim., p. 439.—Lindt, in Diss, de Aluminis Virtute Med- ica. Goet., 1784. — Lafler, BeytrSge zur Wundnrzney- kunst. b. i.—B. Ruspini, Of the Effects of an extraordinary Styptic. Ac, Svo. Lond., 1785.—Ritter, Dissert. Haemor- rhagiarum Pathol. Semeiolog. et Therapia in Geuere, 4to. Marburgi, 17t>5.—P. F. Gmelin, De Usu Vitrioli Ferri ad- versus Haemorrhagias, 8vo. Lips., 1793.—J. P. Frank, De curandis Ilominum Morbis, Svo. Ticini, 1794, 1. v., p. 2.— Darwin. Zoonomia, vol. ii.—/. Binns, History of the Treat- ment of Haemorrhages, Svo. Lond., 1795.—F. Hufeland, Dissert, sistens Pathologiae atq. Therapiae Haemorrh. adunt- brat., 4to. Jaenae, 1797.—De Meza, Act. Reg. Soc. Med. Havn., vol. iii., No. 26.—Reil, Memorab. Clin., vol. ii., fasc. i., No. 1.— Vogel. Dissert, de Val. Crit. Haemorrhage Nari- um et Haemoirhonlum, 4to. Halae, 1792.—Hooper, Memoirs of the Med. Soc. of London, vol. n., p. 509.—Ferriar, Essay on the Medical Properties of the Digitalis Purpurea. Lond., 1799. — G. Panzani, Considerazioni Pathologiche intorno alle Cause e Fenoineni dell' Emorrhagie, Svo. Venice, 1799.—R.Willan, Diseases in London,passim.—T. Gibbons, Medical Cases and Remarks (Part ii., On Nitre in Hamor- rhages), Svo. Sudbury, 1799. Lond., 1801.—Merrier, in Sedillot's Journal. &c, t. xxxv., p. 263—Caliami, in Me- morie di Fisica della Societa Ital. a Modena, t. xii-, p. 2.— Adair, in Brugnatelli, Giornale Fisico-Medico, t. i., n. 21. —Merat, Memoires de la Soc. M6d. d'Emulation, t. vii., p. 193.—Luscombe, Lond. Med. Journal, 1803.—Pagez, Journ. Gen. de Med., t. xxx., p. 3.—F. Gamier, Dissert, sur les Hemorrh. consid. d'une Maniere generate, Svo. Par., 18M. —S. G. Vogel, Handbuch zur Kenntniss und Heilung der Blutfliisse. 8vo. Stendal, 1801.—F. G. L. Chretien, Essai sur lis Hemorrh. Actives, consid. chez 1'Enfant, l'Adulte, et le Vieillard, Svo. Pans, 1803.—A. T. Rey, Essai sur lea Ilemonhagies produites par les Causes Exteraes, Svo. Paris, 1803.—C. J. Meyer, Systematisches Handbuch zur Erkenntniss und Heilung der Bluttliisse. Wien., 1804.— W. Cullen, Works, by /. Thomson, vol. i., p 283; vol. it., p. 201, et srq.— T. Percival, Essays, Ac, vol. ii., p. 185.— P. Pinel, Nosograph. Philosoph., t. ii., p. 569.—A. P. W. Philip, On Symptomatic Fevers, p. 315.—G. A. Spangen- berg, Ueber die Blutfliisse in Medicinischer Hmstcht. *vo. Braunsrhw., 1805.—B. Wollkopf, Untersuchuogen ueber die Erscheinung, Ac, des Biutflusses, 8vo. Leips., 1805.— /. F. T. Jones, A Treatise on the Process employed by Na- ture in suppressing the Haemorrhages from divided Arteries, 8vo. Lond., 1805.—/''. M. O. Legouas, Essai sur les Hem- orrhagies, 4to. Par , 1808.—Otto, Of an Hemorrhagic Dis- position existing in certain Families, M£d. and Phys. Journ., July, 1808 ; Med. Repos., vol. vi — Lordat, Traite'des Hem- orrhagic*, 8vo. Par., 1808.—Sternberg, Horn's Archiv.. b, iv., 1 h.. n. 7.—Doemlung, in Horn's Archiv., b. in p 29, 32— F. Gamier, Diss, sur rHemorrhagies, Svo. Paris 236. - VV. G. Kelch, Ueber das Wesen der Heilung der ILemorrhagien 8v„. Kopenh., IfOO.-Davies, Meu\ and Phys. Jm.rr. J™..]M*.-Joerdens, Hufeland's loam, der Pract. He.lkun.le b x.v.. 4 St., p. \,%-Hufeland, Joum. der Practischen Ile.lkunde, b. vi... p. U2.-R,tttr, Hufe- land's -lournal iler Pr. Arzneyk., h. vii., 3 st., p. o7 -Cons- bruch, Hufeland und Hiwtly's Journal, 1810, May p H6 _ HAEMORRHAGE FROM THE SKIN—Causes. 87 Spangenberg, Horn's Archiv., 1809, May, p. 35.—Hilde- brandt, Horn's Archiv., 1811, September, p. 317.—Heim, Horn's Archiv., 1812, Jan., p. 5, 6, 9, 12, 24.—/. Lordat, Traite des Hemorrhagies, Svo. Pans, 1808.—Pinel et Bricheteau, Diet, des Sciences Medicales, art. Hemorrhagic, vol. xx., p. 325.— W. Rehm, Momenta ad Pathogeniam Haemorrhagiarum Venosarum spectantia, 8vo. Marb., 1816. —Pout, Med.-Chirurg. Soc. Trans., t. xii., p. 167.—M. R. Calve, On the Use of Ice in Haemorrhage, Revue Med., t. iii , p. 199, 1824.—C. H. Parry, Elements of Pathol, and Therap., vol. i., p. 121. 1825.—31. Robert, Nouv. Biblioth. Med., t. ii., 1826, p. 74.—Turner, On Haemorrhage from lacerated Arteries, Trans, of Edin. Med. and Chir. Soc., t. iii., p. 105, 308.—H. G. Jameson, Journ. des Progres des Sciences Med., t. vi. p. 140; t. vii., p. 126; t. ix., p. 150. —N. Smith, Journ. des Progres des Sciences Med., t. ix., p. 118.—R. Coates, On Hereditary Haemorrhage, North Amer. Med. and Surg. Journ., 1828, and Journ. des Pro- gres des Sciences Med., t. xiii., p. 61.—Chomel, Diet, de Med., art. Hemorrhagic, t. xi., p. 35.—D. iMtour, Hist. Philos. et Med. des Causes essent., immediates, ou pro- chaines des Hemorrhagies, 2 vols., 8vo. Pans, 1828.—F. J. V. Broussais, Hist, des Phlegmasies Chroniques, t. ii., p. 119, 129, 541 ; t. iii., p. 146, 519; et Examen des Doc- trines Medicales, Ac. Svo. Par., 1829. — L. C. Roche, Diet, de Med. et de Chirurg. Pract., art. Hemorrhagic—J. Johnson, Med. Chirurg. Review, vol. i., p. 142; Ibid., vol. ii., p. 224 ; Ibid., vol. xi., p. 545; Ibid., vol. xiii., p. 134 ; Ibid., vol. xiii., p. 144. 260; Ibid., vol. xvii., p. 298, 347, 357 ; Ibid., vol. xx., 451 ; Ibid., vol. xv., p. 171 ; Ibid., vol. xi., p. 100; Ibid., vol. iii., p. 16 (Ann. Ser.) ; Ibid., vol. ii., p. 668 ; and Ibid., vol. iv., p. 930.—/. Elliotson, in Medical Gazette, vol. ix., p. 524, 569.—Negri, in Ibid., vol. xiii., p. 361.—L. C. Roche and L. J. Sanson, Nouv. Elcmens de Pathol. Med. Chirurg., t. i., p. 50.—W. P. Dewees, Prac- tice uf Physic, vol. ii., p. 721, Svo. Philadelphia. 1830.—/. F. Lobstein, Traite d'Anatomie Pathologique, t. i., p. 197. —E. F. Dubois, Traite de Pathologie Generate, p. 259, 358, 401.—T. Watson, Cyc. of Pract. Med , vol. ii. Lond., 1833. —R. Carswell, Illustrations of the Elementary Forms of Disease, fasc. 6. Loudon, 1836. [AM. Bibliog. and Refer.—N. Chapman, Lectures on the more important Eruptive Fevers, Haemorrhages, and Dropsies, and on Gout and Rheumatism. Phil., 1844, 8vo, p. 448.—B. Rush, Med. Inquiries and Observations.—D. Hosack, Essays and Lectures on Pract. of Physic.—/. Bell, Am. Ed. of VvtMtams's Prin. of Medicine. Phil., 1844 ; and Lectures on the Pract. of Physic.—R. Coates, in North American Med. Journal.—S. D. Gross, Elements of Patho- logical Anatomy, illustrated by numerous Engravings, 2 vols. Boston, 1839, 8vo.—/. Eberle, A Treatise on the Pract. of Medicine, 2 vols. Phil., 1835.—7'. Stewardson, Am. Ed. of EUiotson's Prin. and Prac. of Med. Phil., 1844.—R. Dun- glison, The Pract. of Medicine—A Treatise on Special Pa- thology and Therapeutics, 2d ed., 2 vols. Phil., 1844.—/. K. Mitchtll, On the Penetrativeness of Fluids, Am. Journ. Med. Sci., vol. vii., p. 36.—Edwin D. Faust, Experiments and Observations on the Endosmose and Exosmose of Gases, Ibid., vol. vii., p. 23.—/. N. Hughes, Transylvania Journal of Medicine, vols. iv. and v.—S. G. Morton, in Am. Ed. of Mackintosh's Pract. of Medicine. Phil., 1844.—Am. Ed. of Tweedie's Library of Medicine.—/. A. Gallup, Outlines of the Institutes of Medicine, founded on the Philosophy of the Human Economy in Health and Disease, 2 vols., Svo, 2d ed., revised. New-York, 18450 hemorrhages considered with respect to their Seats. 57. In treating of haemorrhage, as regards the situations in which it takes place, I shall notice it, First. In parts which admit of the ex- ternal discharge of the effused blood, as from the skin, and from the mucous surfaces ; the latter of these comprising the most important of the diseases usually denominated haemorrhagic. Second. In serous or shut cavities, necessarily followed by a greater or less accumulation of the effused blood. Third. In the areolar tissues or parenchyma of the viscera. In discussing the particular forms of haemorrhage according to this arrangement, due reference will be made to the vital conditions and morbid relations upon which haemorrhages were shown, above, more or less to depend. II. Hemorrhage from the Skin.—Svn. Ham- orrhagia per Cutem; Hamatidrosis, Plouc- quet; Sueur de Sang, Chomel. 58. Dekin.—An exudation of a sanguineous fluid from a part or the whole of the cutaneous surface, most frequently the former, without abra- sion of the cuticle. 59. Haemorrhage very rarely takes place from the whole of the cutaneous surface, and rarely even from a limited part. The effusion of blood under the cuticle, as in scurvy and purpura, &.c, is different from the form now being con- sidered, in which it is external to this tissue. When the haemorrhage is from the cutaneous surface, generally it assumes the form of a san- guineous sweat or perspiration. The situa- tions to which it is most frequently limited are the face or cheeks; the anterior parts of the chest and armpits ; the mammae and mamillae, the groins, the umbilicus ; the palms of the hands and soles of the feet; and the heels, toes, and fingers. It may occur in these situations without any abrasion of the cuticle or change in the skin; but it also sometimes proceeds, both in these and in other parts, from cicatrices, naevi, or other alterations of structure. 60. Haemorrhage from the cutaneous surface generally has been noticed by Beuerenius, Tul- pius, Wepper, Schenck, Garmannus, Ruysch, Lentin, Stahl, Pezold, and Richter ; and a few cases of it are given in the Ephemerides Academia Natura Curiosorum. I never saw an instance of it. My learned and scientific friend, Dr. W. Hutchinson, informed me that, during his residence in the Ukraine, he had a fine Ara- bian horse, whose sweat, upon most occasions of exertion, was sanguineous, and was nearly pure blood upon great exertion. It was gen- eral, and unattended by any other sign of dis- ease. Haemorrhage from the face has been ob- served by Vogel and Pelisson. It has occur red in rare instances during epileptic convul- sions ; I have seen a case of this kind. Dis- charges of blood from the mamma and nipples are more frequent, and have been seen by Schenck, Amatus Lusitanus, Marcellus Do- natus, Mercklinus, Vander Wiel, Panarolus, Paullini, Bierling, Hoffmann, Schurig, Tri- oen, Delius, Richter, Wegelin, Jacobson, and myself. Haemorrhage from the umbilicus has occurred chiefly in young children, or during the first weeks or months of infancy. Cases of this kind have been noticed by Fabricius, Shuster, Radford, and others, and have gener- ally terminated fatally. Mr. Pout has detailed a case which thus terminated, and which was the third in one family. Exudations of blood from the armpits, groins, and extremities, es- pecially the fingers and toes, have been remark- ed by Wepper, Zacutus, Lusitanus, Mercklin, Hagendorn, Ash, Musgrave, Ab-Heers, Ried- lin, Bartholinus, Orlovius, Whytt, and Thi- lenius. Haemorrhage from cutaneous nacvi, and from the cicatrices of ulcers, is not an in- frequent occurrence, especially in females in whom the catamenia are suppressed. In this case it assumes the form of vicarious men- struation. 61. i. Causes.—Cutaneous haemorrhages are evidently more or less connected with the state of the constitution and of the circulation. They have been seen at all ages, and more frequent- ly in females than in males. They most com- monly appear after the suppression or cessa- tion of accustomed sanguineous or other dis- charges, more especially the menstrual. When they take place from the breasts, they often recur periodically, and replace the catamenia. HAEMORRHAGE FROM THE NOSE—Phenomena. They are sometimes caused by great exertion, by violent emotions, by sudden terror or fright, and by great muscular efforts. Mayer states that he saw a case in which the haemorrhage returned twice annually, about the equinoxes, upon muscular exertion. 62. ii. The Phenomena attendant upon cuta- neous haemorrhage have not been closely ob- served or described. In some cases, where the exudation was partial, pain and redness of the surface preceded it. In others, the blood has issued from a greater or less extent of the skin, in a manner similar to the perspiration, of which it seemed to constitute a part. It has varied in deepness of colour and in fluidity, as well as in quantity. Upon wiping it off, the skin has presented no change of structure, and has continued still to exude the blood from its surface. The discharge has seldom been of long duration, although it has frequently recur- red. Where it has been vicarious of menstru- ation, and has proceeded from the mammae, or from naevi, or from a cicatrix, increased ful- ness, redness, and heat of the part have gener- ally preceded it for a short time. 63. iii. The Prognosis of cutaneous haemor- rhage is generally favourable when it is partial, unless it be dependant upon internal disease. When it is general, it is not unattended by dan- ger. The soft solids and the blood itself are then generally more or less in fault; and this seems to be not less the case when it has been caused by violent mental shocks or sudden frights. 64. iv. The Treatment should altogether de- pend upon the states of vascular action and vital power, and ought to be conducted accord- ing to the principles developed above. If the haemorrhage has followed the suppression of an accustomed discharge, the restoration of this latter ought to be attempted. If it has proceeded from fright or moral emotions, anti- spasmodics, restoratives, and sedatives should be administered. If it be evidently passive, and very abundant, it ought to be moderated or restrained by tonic astringents, internally and externally prescribed. Bibliog. and Refer.—Benivenius, De Alxlitis Morbo- rum et Sanat. Causis, c. 4.—Schenck, 1. ii., obs. 288; 1. iv., obs. 266 ; 1. iii., obs. 37.—Amatus Lusitanus, cent, ii., cur. 21 ; cent, vii., cur. 48.—Tulpius, Observ., 1. ii., c. 31.— Mercklinus, Cas. Incantat., n. ix., p. 72.—Zacutus Lusita- nus, Med. Pr. Hist., 1. ii., p. 102, and Prax. Admir., 1. ii., obs. 102.—Wepfer, Exercit. de Apoplex., p. 230.—Hagen- dorn. Cent, ii., obs. 70.— Van der Wiel, Cent, i., obs. 79.— Hoffmannus, in Poter., cent, ii., cap. 56.—Marcellus Dona- tus, 1. iv., cap. 19, p. 410.—Panarolus, Pentec. iv., obs. 16. —Ab-Heers, Observ., No. 23.—Ephem. Nat. Cur., dec. i., ann. ii.; App., obs. 162; ann. iii., obs. 27 ; dec. ii., ann. vii., obs. 199; ann. viii., obs. 86 ; dec. iii., ann. iii., obs. 194 ; cent, viii., App., p. 7 ; dec. iii., ann. vii. et viii., obs. 121 ; cent, vii., obs. 26 ; cent, vii., obs. 81; cent, x., App., p. 464.—Ruysch, Adversar. Anatom. Med. Chir., dec. iii.— Paullini, Observ., cent, iii., No. 42.—Bartholinus, Hist. Anat., cent, i., hist. 13 and 52.— Garmannus, De Mirac. Mort., 1. ii., p. 523.—Ash, Philosoph. Transact., No. 171.— Riedlin, Millenarius, No. 619, 975.—Stahl, in Diss, de Pas- sionibus animi Corpus Humanumvarie altemntibus. Hal., 1691.—Musgrave, Philos. Transact., No. 272.—Fabricius, Sammlung einiger, Ac, h. i. et ii.—Thilenius, Med. u. Chirurg. Bemerk., b. i., p. 286; Act. Erud. Lips., 1702, p. 386 ; Bresl. Samral., 1720, ii., p. 322 ; Commerc. Liter. Nor., 1732, p. 137 ; Select. Med. Francof., t. i.,p. 327.—Schurig, Haematologia, p. 271 ; Art. Med. Berol., dec. i., ann. iv., p. <59.—Delius, Diss, sistens Observ. Medic. Chir. Pract. Er- lang., 1756.—Richter, Medic, und Chirurg. Bemerkungen, p. 15; Observ. Chirurg., fasc. iii., p. 60.— Vogel, in Diss. Decas. Observ. Phys. Med. Chir. Goett., 1768.—Schuster, Medic. Journ., t. v.—Pezold, Observ. Med. Chir., No. 46.— Bierling, Thesaur. Pract., p. 35.—Wegelin, in Stark's Ar- chiv.—Pelisson, in Journ. de Medecine, t. xxiv., p. 227.— Mazars de Cazeles, in Journal de Medecine, t. xxiv., p. 339. —Baudeloque, in Recueil Period., t. v.. p. 318— Dugland, in Ibid., t. v., p. 345.—Orlovius, Pr. de HteinnrrhngiA Spon- tanea ex Apice Pollicis Manus Sinistra. Ki-iriom., 1786.— Horn, in Archiv. der Pract. Ileilkunde fiir Schlesu- w, b. iii., st. 1, n. 2.—Pout, in Trans, of Med. and Chirurg. Soc., vol. xii., p. 167.—Chomel, in Diet, de Med., t. xi., p. 41.—Ja- cobson, in Lond. Med. Gazette, vol. ii., p. 95 (from Rust's Magazin, 1828).- T. Radford, in Edin. Med. nnd Surg. Journ., vol. xxxviii., p. 1. III. Hemorrhage from the Nose. — Syn. 'Em'oraftf (from tirtoru^u, I flow drop by drop); Aiuofrpayia, Hippocrates ; Hamorrha- gia, Linnaeus, Sagar, Sauvages; Hamorrhagia Narinea, Hoffmann; Epistaxis, Vogel, &c.; Hamorrhagia Narium, Sanguinis Stillatio, vel Stillicidium £ Naribus, Auct. var. ; Himorrha- gie nasale, Saignement du Nez, Fr. ; Nasen- bliitfluss, Germ. ; Bleeding from the Nose. 65. Defi.v.—The effusion of blood externally from the pituitary membrane. 66. There is no part of the body more dis- posed to haemorrhage than the pituitary mem- brane, and none in which the recurrence of the discharge is productive of so little injury, as respects either this structure or the constitu- tion. It is necessary to a due consideration of the pathological and therapeutical relations of epistaxis, to recollect that this membrane is supplied by the external and internal branches of the common carotid arteries; and that its blood is returned partly into the external jugu- lar veins, and partially, by anastomozing branch- es of veins, into the anterior veins and sinuses of the cranium. The blood effused from the pituitary membrane may be discharged either by the nostrils, or by the mouth after having passed into the posterior fauces. This latter very generally occurs when the patient is in a supine posture ; it then not infrequently flows into the pharynx, and is swallowed. If the quantity of blood is great which thus passes into the stomach, irritation of this organ, and of the intestinal canal, sometimes followed by vomiting of the blood, by a pseudo-haemateme- sis, or by melaena, not infrequently supervenes. On the other hand, blood may be discharged through the nostrils without having heen effu- sed by the pituitary membrane. This occurs when a sudden or profuse haemorrhage takes place from the pharynx, bronchi, or stomach; but it is not, and therefore should not be con- founded with epistaxis. 67. i. The Phenomena of Epistaxis are well known ; but the signs of its occurrence, and the true pathological states ushering it in, are not so generally recognised or justly estimated. A. The precursory symptoms vary much accord- ing to the grades of vital action, of local deter- mination, and of general or local vascular ful- ness, preceding and attending it; and upon these pathological conditions entirely depend the hypersthenic, sthenic, or asthenic, the en- tonic or atonic, the active or passive charac- ter of the haemorrhage. In proportion as it partakes of a hypersthenic or sthenic form, the more manifestly will it be ushered in by one or more of the following symptoms : by pain of the head or face ; by vertigo, stupor, or som- nolency ; by frightful dreams or restlessness; by redness or heat of one or both cheeks ; in- jection of the eyes or lachrymation ; by flashes of light before the eyes, or affections of the sight; deafness, or noises in the ears; in- creased strength of pulsation in the temporal or carotid arteries, and fulness of the veins • HAEMORRHAGE FROM THE NOSE—Causes. 89 and by a sense of fulness, tension, dryness, heat, or of titillation or itching of the nostrils. Not infrequently, especially in the more passive or asthenic states, the haemorrhage occurs without any premonition, or merely after a Blight touch or local irritation. The character of the pulse varies with the degree of vascular action and of vital power; and, in proportion to the grades of both, it is full, strong, and re- bounding. According, also, as both action and power are weakened, the pulse becomes fre- quent, soft, compressible, open, small, and un- dulating. The older writers considered that a dicrotic or rebounding pulse indicated the oc- currence of this, or of some other haemorrhage; but no great dependance can be placed upon this symptom. 68. B. The haemorrhage may take place from one or both nostrils; but in the latter case it is greater from one than the other. The quan- tity of blood discharged may vary from a few drops to many pounds ; and, in the more obsti- nate passive states, the patient may be reduced to the utmost danger, or may be carried off in a few hours, or days, according to the contin- uance or violence of the discharge. In some cases, a fibrinous and more or less firm coagu- lum attaches itself to the part whence the haemorrhage proceeds, and occasionally hangs out of the nostrils over the upper lip, or down into the posterior fauces. As long as this re- mains attached the discharge continues sup- pressed ; but when removed prematurely or otherwise, it returns, even with increased vio- lence and danger*. The disease may be contin- ued, remittent, and recurrent, or intermittent. In this last case it may return irregularly or peri- odically. 69. C. The more active or simply sthenic epistaxis is often symptomatic or critical of sev- eral acute diseases, attended by increased ac- tion, especially the more inflammatory kinds of fever, and inflammations of the brain, or of the lungs, &c. The passive forms are frequent- ly symptomatic of several cachectic maladies, and of the last stages of malignant or low fevers. Many writers, even as recent as the Franks, suppose that, in cases of epistaxis consequent upon enlargements or obstructions of the liver, or of the spleen, the haemorrhage is generally upon the same side as the enlarged viscus. 70. ii. Causes.—A. Epistaxis occurs most frequently in children and young persons, es- pecially in its more idiopathic states. It affects most commonly the sanguine, irritable, the plethoric, and florid; and those possessed of great talents, of delicate or relaxed fibres, of weak constitutional powers, and of much sen- sibility. After ten or twelve years of age, it is oftener observed in the male than female sex. It is not infrequent in males about the change to the decline of life; and then, as well as at later periods, often prevents more serious haemorrhagic or inflammatory attacks. Epi- staxis is also often dependant upon peculiarity of constitution or diathesis, and is consequent- ly often hereditary, or observed in several of the descendants of the same parents, or mem- bers of the same family. At advanced ages, it is most common in those who live luxuriously and partake largely of wine or malt liquors. [n the more mature periods of life, it is most frequently symptomatic, or dependant upon dis- 12 ease of the heart, of the liver, spleen, or of some other viscus; or consequent upon the disappearance of some sanguineous or other evacuation. 71. B. The exciting causes are extremely numerous and diversified, for whatever favours an increased flux of blood to the head, and to the pituitary membrane, or retards the return of this fluid from these parts; or occasions general plethora; or weakens the vital cohe- sion of this membrane, or the tone of the ves- sels ramified in it, may occasion haemorrhage from it, when the predisposition already exists. —a. The external causes are, injuries ; irritants or excitants inhaled into the nostrils ; stimu- lating vapours or gases ; fractures of adjoining parts; exposure of the face to fires or furna- ces, or of the head to the sun's rays, either uncovered, or with a black or metallic hat or cap.—b. The internal causes are, whatever in- creases the flow of blood to the head, as anger, shame, or other states of mental excitement or mental disorder; protracted study, and great exertions of the mind; stooping, or a low or depending position of the head ; frequent sneez- ing ; catarrh ; febrile, inflammatory, and ex- anthematous diseases ; headaches, and rheu- matic affections of the face ; whatever retards the return of blood, as deep sighs, exertions of the voice, laughing, singing, crying, &c. ; playing on wind instruments ; severe cough, or difficulty of breathing ; sudden terror; dis- ease of the heart or adjoining large vessels; tumours pressing upon the jugular veins, or other causes of obstruction to the circulation in them, or in the subclavians ; congestion of the lungs ; neckcloths or collars worn too tightly round the neck, &c. ; whatever causes absolute or relative plethora, as too full living, the ingurgitation of large quantities of wine, or other exciting liquors ; the suppression of ac- customed evacuations, especially the catame- nial and haemorrhoidal, &c. ; whatever inter- feres with the equal distribution of the blood, as wearing tight clothes or corsets, obstruc- tions in any of the large viscera, the gravid uterus, excessive distention of the stomach or bowels, or enlargement of the spleen, epileptic or convulsive seizures, cold applied to the ex- tremities, suppression or retention of the natu- ral discharges, and unnatural positions of the body; whatever weakens the tone of the ves- sels in the pituitary membrane and diminishes the crasis of the blood, as the advanced states of low fevers, scurvy, and other cachectic mal- adies, frequent returns of the complaint, &c.; whatever determines the blood to the super- ficial parts of the body, as diminished pressure of the air, high range of atmospheric heat, &c. The epidemic prevalence of epistaxis (which is of very rare occurrence) may be attributed to this last cause. (See Morgagni, Epist. xiv., ch. 25.) 72. c. The blood is chiefly exuded from the capillaries of the pituitary membrane, as in haemorrhages from other mucous surfaces; but the question frequently agitated, as to whether it proceeds from arterial or venous capillaries, can hardly be solved, nor does it deserve the trouble of inquiry. J. P. Frank observes that he has frequently seen a varicose state of the veins after cases of chronic epistaxis. The more important considerations as to the pa- 90 HEMORRHAGE FROM thology of the disease are those which relate, 1st. To the states of vascular action, and vital tone attendant upon it; 2d. To the constitution and habit of body of the patient; 3d. To pre- vious attacks of haemorrhage, either from the nose or from other parts ; 4th. To antecedent and associated disorders, or to tendencies to be affected by dangerous maladies, as apoplexy, palsy, haemoptysis, phthysis, &c.; 5th. To the causes, predisposing and exciting ; 6th. To the probable consequences of an immediate arrest, or of a continuance of the discharge ; and, 7th, To its critical influence. 73. iii. The Prognosis should have more or less reference to the circumstances just enu- merated. It is generally favourable when the disease occurs in children, or persons about the age of puberty, who are otherwise healthy; but, if epistaxis affect the cachectic, the stru- mous, those who have evinced a tendency to affections of the lungs, or of the glandular and lymphatic system, or those labouring under disease of the heart, lungs, or spleen, or who are aged, the prognosis ought to be more guarded, inasmuch as the haemorrhage may be difficult to restrain ; or, when arrested, it may return, or may be followed by still more se- rious results, as by haemoptysis, or by an ag- gravation of the associated malady, or by fatal syncope, upon using exertion or assuming a sitting posture. The more sthenic the epi- staxis, the less the risk from it, unless it be prematurely restrained. But when it is mani- festly asthenic and copious—if the means of cure fail, and if the blood is thin, dark, or does not coagulate—if the powers of life sink, and the skin and lips assume a pale or waxy hue, the prognosis should be unfavourable, in proportion to the prominence of these chan- ges. 74. In persons who have arrived at or passed middle age, the above circumstances (y 72) and considerations should especially have due weight; and even the contingencies of the at- tack—whether suppressed, or allowed to con- tinue as far as the immediate safety of the pa- tient will warrant—ought to be fully estima- ted. Where disease of the heart, especially passive dilatation of one or more of its cavi- ties, or attenuation of its structure, or a dispo- sition to apoplexy or palsy, or engorgement of the liver or spleen exists, an opinion of the im- mediate or ultimate consequences should be stated with caution. When slight epistaxis takes place in the plethoric, or in those addict- ed to indulgences at table, the circumstance ought to be viewed as indicating the danger of the habit, and the probable occurrence hereaf- ter of apoplexy or palsy, if a more spare diet and suitable regimen be not observed. In forming an opinion of the terminations of nasal haemorrhage, the remote consequences of the continuance or suppression of it upon related organs should be considered in connexion with the causes and the accompanying phenomena. When the epistaxis appears as a salutary evac- uation of an overloaded vascular system, when it has been caused by full living or intemper- ance, or preceded by headaches, noises in the ears, injected eyes, affections of any of the senses, &c, the prognosis ought to have ref- erence chiefly to the cerebral disease which it has averted; and the indications which it has THE NOSE—Treatment. evinced should not be lost upon the practition- er, nor upon the patient. 75. iv. Treatment.—a. Upon visiting a pa- tient with epistaxis, the first glance will often enable the practitioner to decide whether or not he ought to arrest it without delay. When the countenance does not at first furnish suffi- cient grounds for immediate determination, in- quiries bbght to be made as to the age, consti- tution, habits, and previous ailments of the pa- tient ; the causes which occasioned the at- tack ; the symptoms ushering it in, and attend- ing it; the quantity and appearance of the blood discharged, and the existing indications of internal disease, in order that a safe conclu- sion may be arrived at as to this and other parts of the treatment. When one or more ol the following circumstances appear at all prom- inent, if the patient be robust or plethoric ; if he have lived fully, and drunk wine or malt liquors freely or daily ; if he have experienced active disease in the head, or attacks of con- gestion, or determination of blood to this part; and if headache, redness of the eyes or face, increased heat of the scalp, throbbing of the vessels, or a beating noise in the ears have ushered in the attack, and more especially if they still attend it, the discharge should not be arrested until the vascular system is relieved; and when this is accomplished, the epistaxis will cease of itself. If it should seem to cease prematurely, and particularly if the above symptoms still continue, depletions, purga- tives, and an antiphlogistic regimen ought to be prescribed. 76. b. When it is desirable to arrest the dis- charge, the means of cure should be directed with the intention, 1st, of deriving the current of circulation from the seat of haemorrhage; and, 2d, of constringing the capillaries of the pituitary membrane. With these views, the patient ought to be placed in a cool and airy apartment, with the head elevated, or held up- right, and the feet plunged in warm water. The neck should be bared, and cold fluids as- persed over it and the face, or cold substances applied upon the nape, or upon the forehead. If these fail, evaporating or iced epithems may be placed over the whole of the head, or the cold affusion may be directed to this part, and an active cathartic exhibited. The most ap- propriate cathartics, in such cases, are calomel, with rhubarb or jalap, and the spirits of tur- pentine with castor oil; but a full dose of the latter may be given in two or three hours after the former has been taken. Emetics have been advised by Stoll, but they ought not to be given early in active epistaxis. They are most serviceable when the attack has been in- duced by an overloaded stomach. 77. Bleeding is required chiefly in the cir- cumstances just alluded to (y 75), and in the more sthenic forms of the disease; but it should not be neglected, in these circumstan- ces especially. It may be necessary to repeat it, even oftener than once, and after longer or shorter intervals. The older writers recom- mended bleeding from the feet, and many mod- ern Continental practitioners order leeches to be applied to the anus or to the vulva, when the epistaxis has arisen from the suppression of the haemorrhoidal or catamenial discharge. When it has become habitual, or periodic, and HEMORRHAGE FROM THE NOSE—Treatment. 91 especially if it be vicarious of menstruation, the recurrence of the discharge may be antici- pated by the application of leeches to the tops of the thighs, near the groins ; by aloetic pur- gatives; by the semicupium or hip-bath, and by the exhibition of emmenagogues, especially biborate of soda, with the aloes and mirrh pill. In other circumstances, cupping over the nape or mastoid processes is preferable to other modes of vascular depletion. When the quan- tity of blood discharged is too great to admit of the loss of more, dry cupping in the former situation should not be overlooked. In the great majority of cases, however, the sitting posture, with the head held backward ; cold ap- plied to the face, or a piece of cold metal placed between the nape of the neck and the clothes, and cooling drinks, especially those with acids, nitre, &c, will be sufficient to arrest the dis- charge. 78. c. When active epistaxis has proceeded so far as to require to be arrested, and has still continued, notwithstanding the foregoing means, the treatment then called for is also ap- propriate to the passive or atonic states of trie disease. In these circumstances, the chief re- liance must be placed upon astringents, applied to the pituitary membrane, and taken internal- ly with tonics; upon pressure made locally; and upon the insufflation of substances into the nostrils that may promote the coagula- tion of the effused blood. A solution of the acetate of lead, or of the sulphate or acetate of zinc, or of the sulphate of iron or of copper, or of the sulphate of alumina, or of the vegeta- ble or mineral acids, or of the pyroligneous acid with creasote, or of any of the numerous vegetable astringents (Y 40, 45), may be inject- ed into the nostrils; or lint, moistened with either of them, introduced ; but while astrin- gents are being used locally, the exhibition of them internally should not be neglected. The acetate of lead, with acetic acid, and small do- ses of opium, may be given internally; or other astringents may be taken with tonics ; or small doses of spirits of turpentine resorted to, in the manner above recommended (y 41). 79. Finely levigated astringent powders, es- pecially those of alum and of gall-nuts, may be blown through a quill into the nostrils ; or sub- stances of a glutinous nature may be employed in this manner, particularly powdered gums, as tragacanth or acacia; or astringents may be conjoined with these. Finely powdered char- coal may be employed in the same way. Pun- gent or irritating substances are often of less service than the powdered gums, which will, without exciting the Schneiderian membrane, favour the coagulation of the blood on its sur- face. Plugging the nostrils with lint moistened with some astringent solution is sometimes successful; but when the haemorrhage proceeds from the more posterior parts of the nares, it will fail, unless the lint be pushed so far back- ward as to reach nearly to the pharynx. Care, however, ought to be taken that it does not ir- ritate this part. J. P. Frank advises a piece of the intestine of a pig, closed at one end, to be introduced into the nostrils, and injected with a cold fluid. Some writers recommend thick mucilage, others a paste with charcoal or with astringents, and others the white of egg, to be conveyed into the posterior nares, in or- der to coagulate the effused blood. When a coagulum has formed, either spontaneously or by any of the foregoing means, it ought not to be disturbed for three or four days, or even longer, lest the haemorrhage return. 80. d. Besides the above measures, others have been advised. In order to derive from the seat of haemorrhage, Zacutus Lusitanus directs the cautery to the lower extremities ; Chrestien, warm pediluvia, with mustard flour put into the water; Borelli, bruised nettles to the feet and hands; Niemann, blisters to the nape, and Cheza to the arms; Riedlin, the exhibition of active cathartics; and Celius Aurelianus, cupping on the occiput, Galen on the hypochondrium, and Forestus on the ex- tremities. With the view of constringing the extreme vessels, cold drinks are prescribed by Hoffmann ; cold injections through the nos- trils, by Morand and Morgagni ; the immer- sion of the head in cold water by Darwin; cold clysters, by Leuthner and Andrieu ; and cold applications to the genitals, by Diemer- broeck, Theden, and Mercier. In addition to the local astringents already noticed, powdered agaric is recommended by Rochard ; writing ink, by Riedlin ; lemon juice, by Blankard ; and spider's web, with vinegar, by Chesneau. The introduction of plugs moistened with spir- its of wine is directed by Morgagni and Rath, and with the expressed juice of the common nettle by Pr/evotius ; and plugs consisting of dough, or chalk-paste, by Avicenna and Diem- erbroeck. The injection of a strong solution of isinglass is prescribed by Lentin ; and card- ed lint, drawn or pushed into the posterior nares, is employed by Audoujn. 81. The internal use of the acetate of lead, with opium, is advised by Reynolds and La- tham ; of the phosphoric acid, by Herder ; of the aromatic sulphuric acid, by Hufeland ; and of the ergot of rye, by Spajrani, Cabini, Ryan, and Negri. The first of these may be employ- ed in either the active or passive states of the disease ; but the phosphoric acid is admissible only in the latter. In passive epistaxis, cam- phor, with opium ; the spirits of turpentine, in small and frequent doses, with aromatics and restoratives; the chlorates of potash or of lime; the sulphate of quinine with camphor, &c.; as- afcetida with myrrh, and opiates in small quan- tity (Sydenham), are among the most energetic medicines that can betaken internally ; but ex- ternal means ought also to be resorted to. 82. e. If epistaxis be vicarious of menstrua- tion, the return of an attack should be pre- vented only by endeavouring to restore the cat- amenial discharge. If it be periodic, especially in persons who have suffered from agues, con- gestion or enlargement of the liver or spleen should be dreaded ; and if either be found to exist, deobstruent purgatives, followed by ton- ics, particularly quinine or the other prepara- tions of cinchona, or Fowler's solution of arse- nic, ought to be prescribed ; but local deple- tions should be freely employed previously to these, whenever the liver is the seat of such disorder. When epistaxis occurs in aged per- sons, either the early suppression of the dis- charge, or its continuance, may be followed by serious results. It is generally connected with a disordered state of the circulation within the cranium in such cases. What has been stated 92 H.EMORRHAGE FROM THE NOSE—Treatment.' above will indicate the circumstances in which it will be advisable to interfere ; but repeated blistering behind the ears, in some instances cupping in this situation, a seton in the nape, and other measures which the peculiarities of the case will suggest, with a suitable regimen, ought not to be neglected. 83. /. If the haemorrhage from the nares seems to be critical, the observations offered in the article Crisis are altogether applicable. When it appears in the last stage of low fevers, or in scurvy, or in purpura, and is merely the consequence of the lost tone of the extreme vessels, with diminished vital cohesion of the mucous surfaces, and a deteriorated state of the blood, the treatment directed for the pass- ive form of epistaxis, or for putro-adynamic fever, is quite appropriate, if the discharge be so considerable as to require measures to be adopted for it. 84. g. The after-treatment of epistaxis is often of great importance, especially in persons of middle or advanced age. An attack, whether slight or severe, in those who live fully, ought to be followed by an antiphlogistic regimen. Where the discharge has prematurely ceased, blood-letting should always be prescribed. In order to derive permanent advantage from this treatment, abstinence, regular exercise in the open air, and a due subjection of the mental emotions, ought to be constantly observed. How fatally this may be neglected is shown by the following case: A gentleman, aged about fifty, of a very full habit of body, accustomed to live richly, and to take his wine freely, but not in excess, became subject to severe head- aches. He afterward had an attack of epi- staxis, which continued until the loss of blood was very great, although means were used to arrest it. He recovered, and remained well for many months ; yet his usual diet and regimen were persisted in. His headaches, as may have been expected, returned; he became de- pressed in spirits, and disliked society; but no appropriate treatment was prescribed, or, at most, aperients only were directed. The indi- cations furnished by the epistaxis were entire- ly lost upon the patient and his medical attend- ants ; abstinence was not adopted by the for- mer, nor precautionary blood-letting by the lat- ter. The consequences may be readily antici- pated. He shortly afterward was struck with apoplexy associated with hemiplegia, for which I was consulted just before his death. This is, however, not the only instance of the kind which has come before me in practice. I could state the particulars of several cases in which the neglect of the indications afforded by epi- staxis has been followed by apoplexy, palsy, epilepsy, mania, and inflammation of the brain and its membranes. [The art of the physician will generally be more advantageously displayed in removing the condition of the system which occasions this affection than in checking the haemorrhage it- self. In a vast majority of cases, we look upon it as a salutary effort of nature, which should rather be encouraged than checked, and the recurrence of which may be obviated by pur- ging, low diet, revulsives, moderate exercise, and the avoidance of the exciting causes. The blood should certainly be allowed to flow where there is evidence of cerebral determination, or vascular fulness and force, and the effect may be aided by a general antiphlogistic regimen. But under opposite circumstances the interfe- rence of art will sometimes be required, and the resources pointed out by our author will be ample for perhaps any emergency that may arise. In these cases, where the pulse is fee- ble, the skin cool and pallid, the general strength diminished, and the vital functions languid, we have ample reason to infer a diminution in the fibrinous element of the blood, and our meas- ures should be shaped to supply this deficiency, as already pointed out under article Hamor- rhage. But in the mean time the haemorrhage is immediately to be checked; the patient is, perhaps, already nearly exhausted, and the blood looks thin and of a light colour, as if di- luted with water. We do not believe that any measures are to be depended on, under such cir- cumstances, but actual plugging of the nostrils, which should be done either by dipping dossils of lint in a strong solution of the sulphate of alu- mine, carrying them high up by means of a plug, or by using the dry sponge, which is, perhaps, the more effectual. It has been recommended, where the bleeding proceeds from vessels situ- ated very high up, to tie a piece of catgut to the sponge, carry it through the posterior nares by a probe, and out of the mouth, by which the sponge can be completely drawn up. But this will be found very difficult to execute, besides causing much discomfort to the patient. Mr. Abernethy states that he never failed in ar- resting the haemorrhage by passing up a dossil of lint, wound round a probe, exactly fitted to the cavity of the nostril, and then withdrawing the probe and allowing the compress to remain for several days. Dr. Negrier, of Angers, has lately called attention to a very simple means of arresting epistaxis, which consists in closing with the opposite hand the nostril from which the blood flows, while the arm of the same side is raised perpendicularly above the head. This plan has proved successful in a great number of instances, and may be thus explained. When a person stands in the ordinary posture, with his arms hanging down, the force needed to propel the blood through his upper extremities is about half that which would be required if his arms were raised perpendicularly above his head. But since the force which sends the blood through the carotid arteries is the same as that which causes it to circulate through the brachial arteries, and there is nothing in the mere position of the arms above the head to stimulate the heart to increased action, it is ev- ident that a less vigorous circulation through the carotids must result from the increased force required to carry on the circulation through the upper extremities (Brit, and For. Med. Review, Oct., 1842, p. 550). For cases illustrating the benefits of this treatment, see Braithwaite's Retrospect (Am. ed., No. 7, p. 88). Dr. Buckler has recommended what he terms hamostasis as a remedy for haemorrhage resulting from either rhexis, diapedesis, or from wounds inflicted on blood-vessels ;* also to relieve inflammatory engorgement and remove simple vascular congestion, and restore the balance of the circulation. This consists sim- ply in arresting the circulation in a portion of the body, as the arm or leg, by the application ♦ [Maryland Med. and Surg. Jour., March, 1843, p. 265.] HAEMORRHAGE—Bibliography and References. 93 of a ligature sufficiently tight to allow the blood to permeate the arteries, while the venous cir- culation is completely arrested. In this way a large amount of blood is withdrawn from the circulation, and is as effectually cut off from the brain and other vital organs as if it had been drawn in a basin. In this manner, Dr. B. contends that we can produce syncope, and ex- ert a more powerful control over the heart's action than by the lancet, antimony, or digital- is, while we do not exhaust the vital forces, nor give rise to the ill consequences which the protracted use of most of the sedative agents is likely to do. The plan is at least worthy of trial in the different forms of haemorrhage, as well as in the other cases pointed out by the writer.—(Loc. cit.) Mercury, carried to the point of salivation, has been recommended by Latham, Southey, and others, as almost a specific remedy for obsti- nate haemorrhage; but it certainly ought not to be indiscriminately employed ; and in a cachec- tic or scrofulous state of the system would manifestly prove injurious. Where it proves useful, it doubtless does so by restoring the se- cretions, which are often deranged; and for the relief of which epistaxis occurs as a timely remedy. Where it is the result of metastasis, we are to endeavour to restore the original discharge, whether it be haemorrhoidal or cat- amenial, and to relieve the original affection, of whose derangement it is merely sympto- matic. The ancients appear to have had nearly as correct views with respect to the management of epistaxis as the moderns ; in proof of which we may refer to the works of Hippocrates, Celsus, and Galen. " Since a trickling of blood from the nose," says Paulus ^Egineta, " indicates a fulness in the whole body, or in the head, being occasioned either by expression or contraction, and as a free evacuation would relax them, and diminish the quantity, it may be proper to evacuate where nature points. With this view, I have ventured, in cases of quartan epistaxis, to open the vessels in the nos- trils with the reed called typha. We must not be contented with a small evacuation, but must take away blood in proportion to the strength. Spontaneous haemorrhages from the nose in fe- vers, when critical, are not to be interfered with ; but yet, if the flow of blood be immod- erate, it ought to be restrained. In the first place, tight ligatures ought to be applied to the patient's extremities, and his head elevated. It would appear that a ligature to the privy parts is particularly adapted for restraining bleeding from the nose. The nostrils ought not to be wiped, nor the part irritated, so that a clot of blood may be allowed to form. Let the nose be cooled by a sponge soaked in oxy- crate, and the nostril plugged up with a pledget dipped in some of the astringent applications." According to Hippocrates, profuse bleeding from the nose indicates a disposition to convul- sions, which venaesection is calculated to re- move ; and Galen observes that convulsions are brought on by the unseasonable use of cold applications to stop the haemorrhage, and rec- ommends bleeding from the arm of the side from which the blood flows. Avicenna rec- ommends ligatures to the extremities, and cold and styptic applications to the nose and adjoin- ing parts. Serapion agrees with most of the ancient authorities in commending a mixture of frankincense and aloes, applied on the down of a hare. He also directs to apply a sponge soaked in cold water to the temples and fore- head. When bleeding at the nose occurs in a fever, Rhases forbids us to stop it unless it prove excessive; in which case he directs us to apply a cupping instrument, without scarifi- cation, to the hypochondrium ; to tie ligatures about the testicles ; to pour cold water on the head; and to drink cold water (Adams's Com. in Paul. aEgineta, p. 326).] Biblioo. and Refer.—Hippocrates, Xltplitairnc o\tu>v, v., Opp., p. 406.—Scribonius Largus, De Compos. Medicam., cap. 7.—Aretaus, Chronic, 1. i., cap. 2.—Galen, De Com- pos. Medic. Sec. Loc, 1. iii., c. 4.—Aetius, Tetr. ii., serm. ii., c. 94, 95.—Calius Aurel., p. 403— Paulus Mgin., I. in., c. 24.—Actuarius, 1. vi.—Avicenna, Canon., 1. iii., fen. 5, tract, i., cap. 7.—Rhodius, Cent, i., obs. 89, 90.—Horstius, Opp., iii., p. 41.—Forestus, I. xiii., obs. 10, 13, 14.—Cnme- rarius, Memorab., cent, xv., n. 22. — Petermann, Observ. Med., dec. iii., n. \.—Borellus, Cent, i., obs. 93.—Zacutus Lusitanus, Med. Pr. Hist., 1. i., 64.—Amatus Lusitanus, Cent, ii., cur. 100.—Bartholinus, Anatom. Renov., 1. ii., c. 6 ; et Hist. Anat. Rar., cent, iv., hist. 36.—Schenck, 1. i., obs. 188, 360, 368 ; 1. ii., obs. 78 ; Ephem. Nat. Cur., dec. i., ann. iii., obs. 243 (Continuing for six weeks).—Riverius, Observ. Coinmunic, p. 658, cent. i.—Freitag, Observat., n. 23, 25.—Diemerbroeck, Observ. et Curat. C, n. 62— Fabri- cius Hildamis, Cent, ii., obs. 18.—Augenius Horatius, t. ii., 1. ii., p. 95.—Benedictus, De Re Medica, 1. iv., cap. iv.— Hagendorn, Cent, i., obs. 60.—T. Brugis, Vade Mecum, with a Treatise on Bleeding at the Nose, 12mo. London, 1670.—Sydenham, Opusc, p. 86.—Pravotius, Med. Pauper., p. 239.—/. G. Sartorius, Admiranda Narium Haemorrhiigia, vo. Lond., 1^33. I Ax. Biblioo. and Refer. —(See Bib. of "Hemor- rhage.")] IV. HEMORRHAGE FROM THE MoUTH AND THROAT. —Syv. Hamorrhagia Oris, H. Faucium, Sto- matorrhagia, J. P. Frank; Sanguinis Profluvium ex Ore. Hamorrhoides Oris, Vogel; Hamor- rhagic buccale, Fr. ; Mundblutfluss, Germ. 85. A discharge of blood from one or more of the parts forming the mouth and throat. 86. Haemorrhage may take place to a great or even fatal amount from the gums, the tongue, the fauces, or the pharynx, and even from the insides of the cheeks and lips. Blood is rare- ly, however, discharged from one or more of these parts unless in the advanced stages of cachectic diseases, or of malignant or low fe- vers.—a. Riverius mentions a case in which four or five pounds of blood were discharged from the lips every month. Haemorrhage from this part has been observed also by Zacutus Lusitanus. J. P. Frank met with a case in which it proceeded from varicose veins of the upper lip. I lately saw an instance of varicose veins of this part, but there was no haemorrhage. Bleeding from the interior surface of the cheeks is generally owing to injury from the teeth or to tumours. 87. b. Discharges of blood to a small amount from the gums ate very common, especially in the advanced stages of the diseases just ad- verted to, and more abundantly after suppres- sion of accustomed discharges, as the catame- nial or haemorrhoidal. Vicarious menstruation may even take place from this situation. Se- vere or dangerous haemorrhages from the al- veolar processes have been most frequently caused by the extraction of teeth. Frank has seen several pounds of blood lost from a vari- cose state of the veins of, and in the vicinity of the gums ; and similar discharges have more frequently taken place from tumours in this sit- uation, and from the excessive use of mercury. Vogel met with an instance in which the dis- charge was produced by a combination of mer- cury and belladonna. Hirsch, Frank, and oth- ers have met with periodic haemorrhage from this part vicarious of menstruation. Fatal ef- fusions from the gums have been seen by Hor- stius, Fabricius, Hildanus, and several more recent writers. The occurrence of haemorrhage in this situation in purpura haemorrhagica, scur- vy, and the diseases adverted to above (v 86), is too well known to require farther notice. 88. c. Haemorrhage from the tongue very rare- ly takes place to any very considerable amount, unless in cases of injury of the raninal veins or arteries, as in dividing the franum lingua, when it may prove fatal. Slighter injuries from the teeth, especially during epileptic fits, sel- dom cause more than small discharges of blood. But the more serious diseases to which the tongue is liable (see art. Tongue) may be fol- lowed by dangerous or even fatal haemorrhage. Such instances are recorded by Plater and others. Mari saw 24 lbs. of blood discharged from this part ; and J. P. Frank met with a case of glossitis, which, upon passing into gan- grene, terminated fatally with profuse haemor- rhage. 89. d. Haemorrhage from the palate and fau- ces to a very considerable amount has been ob- served by Bun or., Vogel, Frank, and Kluige. J. P. Frank believes it generally to proceed from a varicose state of the veins in this sit- uation, and hence the appellation Hamorrhoides Oris, applied to it by Vogel and Bundl. He mentions an instance in a young man who, for many years, suffered repeated attacks of haem- orrhage from the state of the veins of the pal- ate, and who was permanently cured, after a profuse discharge, by a strong solution of alum. Portal met with a case where the haemorrhage took place from the uvula. A more or less co- pious effusion.of blood may also proceed from the velum palati or tonsils, especially in the course of cachectic diseases, or as a conse- quence of a varicose state of the veins of the part, or of those in the vicinity. 90. e. Effusions of blood from the surface of the pharynx occur more frequently than is com- monly supposed, and are overlooked in conse- quence of the fluid having passed into the stom- ach. When the haemorrhage from this situa- tion is very considerable, the quantity of blood which is swallowed is often so large as to cause vomiting, and to lead to the supposition that the stomach is the seat of the disease. The small veins in the pharynx are not infrequent- ly varicose or obstructed, and when this is the case, haemorrhage sometimes takes place from comparatively slight causes. The most dan- gerous discharges from this part occur in the ad- vanced stage of putro-adynamic fevers, and of cynanche maligna, in which the pharynx is more or less affected. J. P. Frank has noticed the occasional supervention of pharyngeal haem- orrhage independently of those diseases ; but the subject has been overlooked by other wri- ters. Some years ago I attended a lady, about 70 years of age, residing at St. John's Wood, who complained of dyspeptic disorder compli- cated with psoriasis and sore throat. The veins of the pharynx were reticulated and var- icose. I was afterward called to her suddenly on account of a very severe haemorrhage, attend- ed by vomiting and cough. Much of the blood evidently was brought up from the stomach, but a great part passed directly from the throat. The cough arose from the irritation caused by the fluid on the epiglottis and pharynx. The effusion was arrested for a time by powerful astringents. Two days afterward, the haemor- rhage returned more violently than before, and terminated life before I reached her. On ex- amination after death, the pharynx was found softened, black, and studded with soft aphthous ulcerations, between which dark blood was in- filtrated. The veins of this part were numer- ous and dilated. The stomach contained a considerable quantity of blood. The upper part of the oesophagus was softened and congested in its internal surface. In this case the blood had passed into the stomach, the position in bed having favoured this occurrence, and had irritated this organ so as to produce vomiting. 91. i. The Symptoms and Diagnosis of haem- orrhage from the mouth or throat are not al- ways as distinct as may be supposed, particu- larly as respects the source of the discharge. The symptoms preceding the effusion are very uncertain, and are those most commonly indi- cating congestion of the head or adjoining parts, or disease in one or other of the above situa- tions. Headache, vertigo, noises in the ears ; ILEMORRHAGE FROM THE RESPIRATORY ORGANS. 95 soreness, irritation, titillation, tension, or a sense of fulness or heat in the throat; a bloat- ed appearance of the countenance, and throb- bings of the vessels iri the vicinity sometimes usher in the haemorrhage. If the patient be in bed when attacked, the irritation of the fluid on the glottis causes cough, and the passage of it into the stomach is followed by vomiting, when the quantity is considerable or the stomach ir- ritable. If haemorrhage take place from the pharynx while the patient is asleep, the blood will flow into the stomach; and the first inti- mation of the occurrence will often be the vom- iting of blood. Hence the utmost care is re- quired to distinguish this species of attack from hamoptysis on the one hand, and from hama- temesis on the other, as it may closely simulate either. In order to do this, the mouth ought to be well washed by a slightly astringent and colourless fluid, or the throat gargled, and af- terward carefully examined. If the haemor- rhage be too copious to admit of inspection of the mouth and throat, the patient should lean forward so as to allow the blood a free passage from the mouth; and if it flow without cough- ing or retching, and is neither frothy or very florid, nor very dark or grumous, there can be no doubt as to the situation whence it proceeds. If the patient feel it collect in the throat, and create a disposition to deglutition, or if he re- quire no effort to bring or hawk it up, it mani- festly proceeds from the fauces or pharynx. In many instances, causing the patient to drink some fluid instantly before examining the throat will assist the diagnosis; and in others, the history of the case will be sufficient to settle the question. When the fauces or pharynx is the seat of the discharge, deglutition of food or drink, or the use of a gargle, either before or during the haemorrhage, will cause more or less pain. (See Diagnosis of Haemoptysis and H^ematemesis.) 92. ii. The Causes of stomatorrhagia are those of haemorrhages generally, but more es- pecially previous diseases of a cachectic or ma- lignant character; affections of the gums and teeth ; repeated attacks of sore throat, partic- ularly when connected with chronic disorder of the stomach and other digestive organs ; the use of mercury ; injury or previous lesion of the vessels, especially the veins; and ob- structed discharges, as the catamenial or haem- orrhoidal, of either of which the haemorrhage from the mouth may be vicarious. The acro- narcotic poisons may even cause it. In a case of poisoning by aconitum, which I saw some years ago, remarkable swelling of the tongue and fauces took place, followed by moderate haemorrhage from these parts. 93. iii. The Prognosis entirely depends upon the circumstances in which stomatorrhagia oc- curs, upon the previous state of disease, and upon the quantity of blood lost, and the effect thereby produced upon the constitution. The general principles above stated will also guide the practitioner. 94. iv. The Treatment of haemorrhage from the mouth or throat requires to be materially modified, according to the parts from which the blood is effused, and the causes producing the effusion. Cases rarely occur in which it is either necessary or proper to have recourse to blood-letting. Purgatives, however, especially those of a stomachic or tonic kind, are often beneficial, more particularly when the disease is connected with disorder of the digestive or- gans, and with accumulations of morbid mat- ters in the prima via. The chief dependance is to be placed in the local and internal use of the more energetic astringents noticed above, as the sulphates, the acetate acid with creasote, the acetate of lead or of zinc, spirits of turpen- tine, the chloride of lime, &c. These may be used in gargles, in more or less concentrated solutions, and in various states pf combination, as with gums or mucilages. If the haemor- rhage take place from a single vessel, or from a limited extent of surface, the actual or poten- tial cautery is quite appropriate. If it proceed from the alveolar process, powerful styptics, and various mechanical measures, may be re- sorted to. 95. When haemorrhage from the mouth de- pends upon general cachexia, or supervenes in the latter stages of putro-adynamic fever, or of purpura or scurvy, the above means should be aided by the internal use of tonics, conjoin- ed with vegetable or other astringents and an- tiseptics, as the chlorides, the chlorate of pot- ash, the nitrate of potash, or the hydrochlorate of ammonia, &c, and by an appropriate regi- men. If the effusion seems to proceed from the pharynx, the position of the patient should be such as will favour the flow of the blood from the mouth, and prevent it from irritating, or escaping into the larynx. Bibliog. and Refer.—Celsus, 1. iv., c. 4.—Avicenna, Canon., 1. iii., fen. 8, tract, i., ch. 3.—Plater, Observ., 1. iii., p. 773.—Rolfink, Diss, de Variolis. Jen., 1658.—Bootius, De Affect. Omissis, cap. 7.—Horstius, Opp., ii., p. 279.— Riverius, Observat. Commun., p. 660.—Af. Cagnati, Obser- vat., 1. iv. ; Ephem. Nat Cur., cent, vii., obs. 73.— Zacutus Lusitanus, Med. Pr., 1. ii., hist. 10; Prax. Admir., 1. i., obs. 84, 85, 90, 91', 92.—Fabricius Hildanus, Cent, vi., obs. 77. —Meckrew, Observ. Med. Chir., c 17.—Biindl, in Diss. Obs. Morb. Rar. (Hamorrhoides oris).—Barlholinus, Hist. Anat., cent, i., n. 19.—Schurig, Hsematologia, p. 254, 256. —Solennander, Cousih, sect, v., n. 15.—Fischer, Diss, de Hxmorrhoidibus Exhalato profluentibus. Erf., 1723. — Biichner, Miscell., 1730, p. 1139.— Vogel, Diss, de Rariori- bus quibusdam Morbis. Goett., 1762, p. 23 ; Eicken Samm- lung, b. i , p. 69.—Jourdain, Des Maladies de la Bouche, t. ii., p. 605.—Ranoi, in Act. Reg. Soc. Med. Hav., vol. iii., p. 362.—Hirsch, Loder's Joum. fur die Chirurgie, b. i., p. 356.—Mari, in Nouva Giornale della pui Rece.nte Litt. Med. Chir., t. iii., p. 198.— Wichmann, Ideen zur DiaKnostik, b. i., p. 89,93.—Thiel, in Loder's Journ. fiir die Chirurgie, b. ii., p. 384.—/. P. Frank, De Curand. Horn. Morbis, 1. v., pars ii., t. vi.. I) 595.—Portal, Cours d'Anatomie Med., t. iv., p. 507.—Kluige, in Hufeland's Journ. der Pr. Arzneyk, b. v., p. 180. V. HEMORRHAGE FROM THE RESPIRATORY OR- GANS.—Syn. Hamoptysis (from alua, blood, and 7rri;(j, I spit, or nrvatc, a spitting); al- fioitTvctgl aipoirrvlnor, Galen, Dioscorides ; Sanguinis Sputum, Celsus; Emoptoe, Gor- don ; Sputum Cruentum, Cruenta Expuitio, Sanguinis Fluor, Vomitus Pulmonis, Auct. Lat.; Mmoptoica Passio, Gilbert; Passio hamopto'ica, Plater ; Hamopto'e, Boerhaave, Vogel, Darwin ; Hamotismus, Auct. var. ; Hamoptysis, Sauvages, Vogel, Cullen, &c.; Hamorrhagia Pulmonum, Ham. bronchica, Hamorrhaa pulmonalis, Auct. var.; Pneumon- orrhagia, J. P. et J. Frank ; Blutspeyen, Blut- hustcn, Lungcnblutfluss, Germ. ; Crachement de Sang, Expectoration de Sang, Fr.; Emotisi, Emotisea, Sputo di Sangue, Ital.; Blodspyting, Dan.; Pulmonary Hamorrhage, Spitting of Blood, Coughing of Blood. 96. Defin.—After a sense of heat, oppression, 96 ILEMORRHAGE FROM THE RESPIRATORY ORGANS. or pain in the chest, and titillation in the throat, the rejection of florid, frothy, or pure blood from the bronchi or lungs, with a hawking or short cough. 97. Hamoptysis is one of the most frequent varieties of haemorrhage, owing to (a) the very extensive bronchial and vesicular surface to which the blood is circulated for the purpose of undergoing the requisite changes during res- piration ; (b) to the delicate conformation of the capillaries and mucous membrane of this part; (c) to the liability of the lungs to conges- tions, from impaired organic nervous power, from obstructions of the pulmonary veins and of the circulation through the left side of the heart, and from tubercular or other lesions of the substance of the lungs ; (d) and to the lia- bility of this organ to derangements of its cir- culation from hypertrophy and other lesions of the heart, and from alterations of the large vessels. Of all these morbid causes and con- nexions, tubercular formations in the lungs are the most common, either as a cause of the haemoptysis, or as associated lesions conse- quent upon the same antecedent changes in the states of vital power and vascular action, or as both. 98. i. Symptoms, &c. — A. The premonitory signs of haemoptysis are, horripilations, passing redness and heat of the face, or flushings of the cheeks, headache, coldness of the extremi- ties, with a collapsed or empty state of the veins of the surface; lassitude, and sense of weight of the limbs ; occasionally cramps or spasms of the lower extremities ; a feeling of internal warmth, particularly in the chest; pain or tension at the epigastrium or hypo- chondria ; a burning sensation under the ster- num, with more or less anxiety, inquietude, constriction, or oppression at the chest, or dyspnoea; a short, dry cough; dyspnoea, or shortness of breath on slight exertion ; a dull pain or soreness under the sternum, between the shoulders, or beneath the clavicles; palpi- tations ; a quick, hurried, or excited pulse, which is sometimes also hard, full, bounding, or oppressed, &c.; flatulence, or borborygmi, costiveness, and pale urine. A few only of these symptoms, or several variously modified, may be present in individual cases ; they may exist for a longer or shorter time before the attack. In some instances, neither cough, nor difficulty of breathing, nor any symptom refer- rible to the chest, has been complained of; or it has existed in so slight a degree as to es- cape the observation of the friends of the pa- tient ; and yet the most extensive changes had taken place in the lungs, and caused the haemorrhage. A case of this kind was attended by Mr. Bushell, Dr. Clark, and myself while this article passed through the press. Such instances, however, are not uncommon, as shown by Rhodius, Muller, Wedel, Gram- berg, the Franks, Louis, Clark, and others. 99. B. Progress.—As the blood rises to the larynx, a sense of titillation is felt in the tra- chea, or of irritation in the throat, with dysp- noea ; and a gurgling or bubbling sensation in the chest or trachea; and the blood is either hawked or coughed up, exciting a sweetish- salt taste. As soon as this occurs, much alarm is sometimes caused, particularly in delicate or nervous persons ; and several of the general symptoms, particularly those connected with the action of the heart and pulse, are owing chiefly to this circumstance. When the blood is in considerable quantity, the discharge of it is attended with a feeling of suffocation; the chest is forcibly dilated, a convulsive reaction or cough follows, and this fluid is ejected from both the mouth and nostrils. In some instances the irritation at the top of the pharynx and in the fauces excites retchings ; and in others the blood, as it collects in the pharynx, is in- stinctively swallowed; and, when it has accu- mulated in the stomach, causes vomiting, and gives rise to a suspicion, from this circum- stance and from the presence of portions of ingesta, &c., as shown hereafter (v 118), that the haemorrhage is seated in the stomach. Oc- casionally the blood is brought up without any effort whatever, beyond a strong expiration, which it accompanies in a full stream ; and when retching or full vomiting is occasioned in the manner just stated, another, and often a greater discharge of blood from the lungs at- tends it. 100. The quantity thus discharged varies from a few drops to many pounds. Rhodius (Obs., cent, ii., 31) saw 23 lbs. lost in three hours; Pezold (Obs. Med. Chir., No. 49) and Zacchiroli (Weigel's Ital. Bibliolh., b. iii., p. 154) observed larger quantities during a much longer period. J. Frank (Prax. Med., &c, ii., 2, 1, p. 417) had a patient who lost 192 ounces in twenty-four hours; and a friend of my own experienced nearly as great a discharge in the same time, and afterward recovered. [Dr. Chapman states that he once saw two quarts come away in twenty or thirty minutes.* We have seen a still larger quantity, in one instance, discharged in the course of an hour. Laennec says that he has known 30 pounds lost in about 15 days, and, in a very extraordinary case, 10 pounds in 48 minutes. J. Frank speaks of a case in which 25 pounds of blood were voided in three hours.] When the blood is not con- siderable as to quantity, it is frothy, or contains bubbles of air, and is of a florid hue ; when it is very abundant, it is fluid, generally more or less florid, but not frothy; it is seldom mixed with muco-puriform matter, unless it be small in quantity, and it then is often semi-coagula- ted, and of a darker or brownish tint; but to- wards the termination of an attack this appear- ance is very common. If the haemorrhage is very great, extreme faintness, or even full syn- cope, may come on; but a sense of depression, or sinking, with a quick, sibilous, and short res- piration ; a small, weak, interrupted voice and speech ; and coldness of the extremities, are more commonly complained of. Occasionally, the least exertion of the voice, or of the body, or a fit of coughing, increases or brings back the discharge ; but as often it returns without any such cause. 101. In some instances the attack is follow- ed by great frequency of the pulse, and gener- ally excited vascular action, with heat of skin, thirst, &c, although the pulse had been per- fectly natural before or at the time of seizure. In these the congestion of the substance of the lungs connected with the production of the haemoptysis has passed into inflammatory ac- * Lectures on the more important Eruptive Fevers, Hemorrhages, &c, p. 173. Phil., 1844. HEMORRHAGE FROM THE RESPIRATORY ORGANS. 97 tion, in one or several parts of the organ ; or, rather, the infiltration of a portion of the effused blood through the smaller bronchi has excited inflammation of them, as demonstrated by the stethoscope and by dissection. In many cases, especially when the haemorrhage occurs in weak or lax frames, and scrofulous or tubercular states of the lungs, not only the external dis- charge of the blood, but also its passage along the bronchi into the more depending parts of the organ, and even its infiltration into the sub- stance of the lungs, or its effusion in the dis- tinct form of pulmonary apoplexy, takes place, as I have several times recognised during life, and ascertained afterward by dissection. 102. An attack of haemoptysis may be so se- vere and sudden as to suffocate the patient be- fore a large quantity of blood is lost; or so continued as to destroy life by the loss of this fluid. Only one violent seizure may occur, the patient recovering perfectly, without suf- fering materially, after the immediate effects have passed off; but this is seldom the case, more or less disease of the lungs, although un- apparent to the friends previous to the attack, following rapidly afterward. In some cases, particularly when tubercles have proceeded to softening, &c, without exciting much disorder, the haemorrhagic congestion, infiltration, and atonic inflammation of the substance of the lungs, attendant and consequent upon the seiz- ure, soon destroy life. In several instances to which I have b'een called, the patients had pursued their usual avocations, unconscious of ailment, been attacked by haemoptysis, and died in three or four weeks afterward in conse- quence of these associated lesions of the lungs. In the case above alluded to (y 98) death took place 26 days after the attack. More frequently the haemoptysis is followed by pulmonary con- sumption in a much less rapid form. When the blood is ejected in small quantity, or of a brown colour, or is mixed with a rose-coloured lymph, or mucus, latent inflammation or active congestion most likely will be found to exist in the substance of the lungs ; and this inference ought not be doubted, if febrile symptoms, with cough, be present, or if the blood taken from the arm be buffed. In a few instances, the lymph effused from the vessels towards the close of the attack is moulded into the form of several bronchi, and is expectorated in this state; in others, cretaceous or other earthy concretions, consequent on the degeneration, or the partial absorption of tubercles, or even ossific matters, are brought up with the blood, or soon afterward; but most frequently, and especially when the haemorrhage is scanty, or towards its close, or after more than one at- tack, muco-puriform matter, with or without minute portions of softened tubercular sub- stance, may be detected ; and these become more manifest as the blood disappears. 103. Haemoptysis may recur at irregular, or even at distant periods ; the patient experien- cing but little ailment in the intervals, or pre- senting merely a marked susceptibility to con- gestion or inflammatory affections of the lungs. When supplemental of suppressed or retained catamenia, or of the disappearance of haemor- rhoids or epistaxis, it sometimes returns peri- odically. In such cases, the evacuation de- pends more upon vascular plethora than upon II 13 serious lesion of the substance of the lungs, although this may also exist. Some instances of a constitutional recurrence of haemoptysis (Y 49) have been observed, and yet a far ad- vanced age has been reached. [Dr. Chapman mentions the case of a lady who, for eleven successive days, had haemop- tysis at precisely nine o'clock in the morning, always preceded by a slight chill.—(Loc. cit., p. 173.) Many similar cases are on record.] 104. C. The appearances after death comprise almost every lesion to which the lungs, heart, and large vessels are liable, but some of them are more immediately connected with haemop- tysis than others. Tubercles are the most common of all these, in one stage or other of their progress, and frequently they are found in every stage even in the same case — either disseminated through the lungs or clustered, in a crude, softened, and ulcerated state, in con- nexion with small or large excavations — in some instances the seats of the softened and partially absorbed tubercular matter containing earthy or cretaceous concretions ; and, in rarer cases, the parenchyma of.the lungs around them presenting a cicatrized or puckered ap- pearance. When haemoptysis has been very recent, the lungs are frequently more or less congested, and their substance infiltrated with dark blood, both throughout many of the minute bronchi and cells, and in the connecting cellu- lar or parenchymatous tissue, large portions of the organ exhibiting a spleen-like appear- ance. In some cases, portions of the lungs are more or less obviously inflamed; the in- flammatory appearances having been either antecedent to, or consequent upon the haemor- rhage, most frequently the latter. In rarer in- stances, blood is effused in the substance of the organ, forming a distinct cavity filled with coagulated blood. 105. Adhesions between the pulmonary and costal or diaphragmatic pleura, both old and re- cent, frequently exist. The bronchial mem- brane is generally injected, congested, and of a deep or dark red, or purplish, or nearly black, either throughout a large extent, or in parts or patches ; but the state and colour of this sur- face vary with the period at which haemoptysis took place, and the mode in which the disease of the lungs terminated the life of the patient. (See art. Bronchi, y 3-14.) In rarer cases, gangrene of portions of the lungs, or erosion or ulceration of one or more vessels connected with softened tubercles or cavities, is observed. These cavities are generally lined with a more or less thick secreting membrane. In a few instances, osseous deposite has been found in the membrane of the cyst. (See art. Lungs.) 106. Alterations of the large vessels in the- chest, and of the heart itself, are oecasionally found, especially in the cases of aged persons. The pulmonary veins have been seen diseased, inflamed, or partially obstructed by humours, or morbid depositions, either externally or in- ternally. I found them inflamed, and a large branch partially obstructed by lymph, in one case. A dilated or varicose state of the pul- monary veins has been noticed in connexion with haemoptysis, by Morgagni, Gillibkrt,. Portal, and J. Frank. Lesions of the pul- monary artery have also been met with, espe- cially rupture (Matani, De Aneurism, Pracordion.. 93 ILEMORRHAGE FROM THE RESPIRATORY ORGANS. Morbis, p. 120) and aneurismal dilatation (J. ] Frank, &c). Mr. Semple has detailed a case which he considered haematemesis, but which j was probably haemoptysis attended with vomit- J ing, owing to the circumstances above pointed out (v 99), wherein the left pulmonary artery , was obliterated, and the lung was extensively diseased. Aneurisms of some part of the aorta opening into the trachea, bronchi, or lungs, have been oftener observed than these. Cruick- shanks found the lymphatics of the lungs tur- gid with blood, absorbed from the air cells, in patients who had died of haemoptysis. 107. Diseases of the heart, particularly such as occasion obstructed circulation through the left cavities, as narrowing of the auriculo-ven- tricular opening, lesions of the valves, &c., are not infrequently found in connexion with hae- moptysis (Wilson, Watson, &c). Hypertrophy of the ventricles, especially of the right ventri- cle, has been remarked, in rare instances. Bertin, Bouillaud, and other French writers, attach considerable importance to this lesion as a cause of the haemorrhage; but I agree with Dr. Watson in considering the alterations which obstruct the passage of blood from the lungs as more frequent causes than this. 108. ii. Causes.—A. The Predisposing Causes of haemoptysis comprise most of those already enumerated in connexion with hamorrhage gen- erally (y 21), and of those which favour the formation of tubercular consumption. (See that article.) Those which are more especially concerned in the production of haemorrhage from the respiratory organs are: Hereditary constitution ; the scrofulous and the haemor- ehagic diathesis ; sanguineous, irritable, and sanguineo-irritable temperaments ; a plethoric habit of body ; the period of life between sev- enteen and thirty-five ; tallness of stature ; a narrow or deformed chest, curvatures of the spine, rickets, or severe hooping-cough in early life; sedentary occupations, especially at the writing-desk or drawing-table ; a change of modes of fife, as from active employments to inactivity ; certain trades, as shoe-making and weaving; the spring and summer seasons : sudden or frequent vicissitudes of temperature and weather, especially rapid changes from cold to heat; suppression of accustomed ex- cretions and discharges ; and congestions or enlargements of the liver or spleen. M. Louis found haemoptysis to occur among men nearly in the same proportion at all ages. Gal ex, Strampin, Goltz, and Louis consider it to be more frequent in females than in males. Frank and Conking entertain a different opinion ; the latter remarks that men are more prone to the disease than females, unless when the cata- menia of the latter are suppressed. Louis found it more frequent in females in the pro- portion of three to two, and that their age was most commonly from 40 to 65. I believe that the predisposition to haemoptysis is less, or at least not greater, in females than in males, un- til the period at which menstruation usually ceases, but that, after this period, the frequent occurrence of vascular plethora favours the production of pulmonary haemorrhage. There is no doubt of the influence of premature and excessive venereal indulgences, and more espe- cially of solitary vices of this kind, in favouring the occurrence of this and its allied diseases. 109. B. The Exciting Causes are chiefly ex- ternal injury ; fracture of the bones of the tho- rax ; wounds of the chest and lungs ; falls or concussions on the chest; physical efforts, par- ticularly in lifting or carrying great weights ; compression of the thorax by straight lacmi;. y the Italian physicians, in large doses, con- joined with demulcents. They give from three to six drachms in twenty hours. It is also beneficially associated with camphor, the ace- tate of ammonia, and sweet spirits of nitre (F. 95, 294, 747), or with the boracic acid (F. 644), .and with conserve of roses. The hydrochlorate * Dr. A. T. Thomson states that this styptic consists of : gallic acid, a small proportion of the sulphate of zinc, and of opium, dissolved in a mixture of alcohol and rose-water. This combination is judicious in most hemorrhages. of ammonia is equally serviceable, especially in the more passive states of haemoptysis, when it is advantageously conjoined with muriatic acid (F. 864). Lentin advises it to be taken in half a drachm every two hours, with an equal part of extract of liquorice. The inter- nal use of ices or of iced fluids has been advo- cated by many writers ; but, like all other ac- tive means, they require discrimination. In the passive states of the disease, where asthe- nia is apparent, the circulation languid, and the temperature not much above the natural stand- ard, they are injurious. 133. /. Alvine evacuations are serviceable by removing morbid matters and obstructions to the portal circulation, and by deriving from the seat of haemorrhage. Purgatives ought, therefore, never to be neglected; and, unless when the haemoptysis is so abundant as to be alarming, they should precede, or be alternated with astringents ; or such of these latter as will not confine the bowels ought to be select- ed. The exhibition of an emetic previous to the purgative has been advised, especially by Stoll, Darwin, Plenciz, Ranoe, Doemling, Paulini, and Schmidtmann ; while Frank and some others think them hazardous. When the haemorrhage has been already copious, or after blood-letting has been resorted to, an emetic of ipecacuanha, or of sulphate of zinc, or of a combination of both, is serviceable, not only in aiding the arrest of the effusion, but also in evacuating the blood accumulated in the bron- chi, and thereby preventing the ill effects which this fluid would produce if it were allowed to remain. It is not merely the vomiting caused by an emetic which is beneficial, but the effect which is produced upon the heart's action. It is with reference chiefly to this latter operation —to its contra-stimulant action—that emetics and nauseants have been recently employed on the Continent, especially in Italy, and by La- ennec and others in France. In the passive or asthenic forms of the disease, nauseants, especially the tartar emetic, may be injurious, even in the same case wherein an emetic of sulphate of zinc might prove of service. As to purgatives, the neutral salts, with an excess of acids, as the sulphates, with sulphuric acid in infusion of roses, or the bi-tartrate of potash in the form of electuary, are the most generally appropriate, with the exception, perhaps, of oil of turpentine, conjoined with castor oil. These oils are the most beneficial: they may be taken on the surface of an aromatic water or of milk, and be administered in enemata. 134. g. In exhibiting anodynes or sedatives, the probability of their being injurious in the asthenic states of haemoptysis should be recol- lected. When the powers of the system are inadequate to procure the excretion of the fluid effused into the bronchi, they ought to be giv- en with caution, or in conjunction with tonio astringents, or with expectorants. Colchicum has been recently recommended; but it is only in the active states of the disease that it ought to be exhibited (F. 545). Digitalis, however, is more generally prescribed. It is recom- mended by Withering, Jones, Ferriar, Heu- singer, Valentin, Carson, Henry, Horn, and others. It may he conjoined with astringents (F. 544), narcotics, or other appropriate reme- dies (F. 514, 515). In the case of a physician HEMORRHAGE FROM THE RESPIRATORY ORGANS. 105 recently under my care, the secale cornutum proved of great service. It was given in doses of five or ten grains every three or four hours, or every hour until an effect was produced. It has been much praised by Spazani, Negri, and Ryan. Narcotics are most serviceable when cough is urgent, by allaying the irritation, and diminishing the risk of the perpetuation or re- currence of the effusion from this cause ; but when the haemorrhage has ceased, and when breathing is difficult, the lungs congested, or the bronchi obstructed by the effused blood, narcotics, especially in large doses, will only retard the discharge of the effused blood and increase the mischief, unless they be conjoined with expectorants, as the senega or benzoin, benzoic acid, myrrh, asafcetida, the balsams of Peru or of Tolu, the terebinthinates, or cam- phor. In the passive states of the disease, or after large losses of blood, the balsams, both natural and artificial, especially those prescri- bed in the Appendix (F. 18-22), are often ben- eficial. The balsam of Locatelli is very much employed on the Continent in haemoptysis, and from its composition it seems very appropriate to most circumstances of the disease. The turpentine is the active ingredient, not only of it, but of the other artificial balsams prescribed in haemorrhagic affections. The following is the usual mode of preparing it: No. 241. R Olei Olivas Jviij.; Terebinthina;, Cera? flavae, 41 Jiv. ; Pulv. subtiliss. Ligni Santali rubri Jss. Ceram in Olei pauxillo solve, dein reliquum, Terebinthinam, Lig- numque Santali adde, et assidue move donee refrixerunt. 135. h. There have been various other means recommended for the arrest of haemoptysis, but many of them are not deserving of notice, and are therefore not here adverted to. The ap- plication of ligatures on the extremities was a disputed practice with the ancients, although most of them recommended them. J. P. Frank and J. Frank approve of them, and direct them to be placed high above the knees and elbows in such cases as admit not of blood-letting, owing either to the profuse haemorrhage or to constitutional adynamia. Ipecacuanha, in small doses, frequently repeated, is praised by Loef- fler, Hennings, Aaskow, Keck, and Niemann ; and by De Meza and Horn, conjoined with opium; a strong solution of common salt, by Percival, Doemling, Michaelis, and Rush ; the turpentines by Young, Boyle, Adair, and the author; and the comfrey, with aromatic sulphuric acid, by Wendt. With Marrvat and numerous practitioners, mixtures, contain- ing nitre or alum, gums, and some one of the balsams, constituted the principal anti-haemor- rhagic remedies ; and vascular depletions were prescribed. It cannot be doubted that blood- letting is often unnecessarily directed in hse- moptysis, or carried too far ; but in the active or inflammatory states of the disease, and when the discharge is scanty or small, it should not be neglected. 136. i. A few authors have questioned the propriety of arresting the effusion in certain circumstances. Dr. A. T. Thomson remarks that when the haemoptysis " is not of an alarm- ing character, and there is no obvious predis- position to tubercular consumption, especially if it be the consequence of a suppression of the menstrual discharge, it should only be mod- erated, not checked suddenly, which might in- 14 duce a congestion in some organ less capable of supporting it with impunity." This is most dangerous doctrine ; for if the haemorrhage be judiciously treated, the sooner it ceases in con- sequence the better. Haemoptysis, in the cir- cumstances stated by this writer, ought to be treated by depletions, derivatives, and other measures calculated to restore any suppressed discharge. The cases are very few in which there is no " obvious predisposition to tuber- cular consumption," and they are still fewer in which the suppressed discharge is the cause of the pulmonary disease ; this latter, in either its more concealed or obvious states, almost always preceding, and even being the chief cause of the suppression. It should be kept in view that, however moderate the haemorrhage may appear to be, it is difficult to determine how far it may be attended by infiltration of the bronchi; and that the continuance of it, by filling these vessels, will risk the superven- tion of inflammatory irritation or action in them, and often also in the substance of the lungs and pleura, as well as hasten the devel- opment and progress of the tubercular produc- tions. [We deem it of the first importance, when called to a patient with haemoptysis, to calm his mind, and, if possible, allay his apprehen- sion, which is generally much excited. The flow of blood is always alarming, and is too oft- en, perhaps, regarded as a highly dangerous symptom. While the blood is flowing, our prac- tice, in all cases, is to immerse the feet and legs in a hot mustard bath, as the revulsion thus produced is extremely beneficial. In addition to these means (and bleeding is rarely if ever admissible) if the haemoptysis be tubercular, we apply a large sinapism between the shoul- ders, or over the front of the chest, and admin- ister a stimulating enema of salt and water, and a saline cathartic. Small quantities of ice or ice-water should be frequently swallowed; and, in addition to this, tea-spoonful doses of the chloride of sodium may be administered every fifteen or twenty minutes.* Many of our practitioners place great confidence in the ni- trate of potash in this disease; but we have never seen any very decidedly beneficial effects from its use. The application of cold water to the chest seems to us of very doubtful propri- ety. To prevent the recurrence of the haem- orrhage, the pill, plumb, opiat. will be found as useful as any other preparation, although we have seen prompt relief from the use of the turpentine, in doses of ten drops every fifteen minutes during the spitting of blood, as recom- mended by Mr. Copland. This exercises a * [Ourexperience relative to the use of this article differs from that of Dr. Dunglison, whostates (" Pract. of Med " 2J. ed., Phil., 1844) that he has never had the slightest reason for believing that it has been productive of any ad- vantage. Dr. Chapman,however, speaks favourably of it and intimates that it operates efficaciously by creating a stronger impression on the parts with which the vessels of the lungs have the most intimate sympathy. (" Led on the more important Eruptive Fevers. Hamorrhages and Dropsies, andon Gout and Rheumatism." Phil., 1844 ) There can be no doubt, we think, that it also acts bv stimulating the capillary vessels by its speedy introduction into the blood. This article was first introduced to the notice of the profession, as a prompt and efficient remedy in hemop- tysis, by Dr. Rush. It would seem, however, from Schopf s account of his Travels in the United States (Bd i., p. 116), that the knowledge of its powers in this wa'v was first brought to this country by Schiel from Ireland J 106 HEMORRHAGE FROM THE RESPIRATORY ORGANS. speedy influence over the capillaries, being rap- i idly taken into the circulation, and manifesting its presence in the urine and breath in a very sensible manner. Tannic acid is depended on by some practitioners, and doubtless deserves | a trial if the means above recommended should fail. It may be given as follows : R. Acid Tan- nic, gr. iv.; Pulv. Acac., gr. xvi. ; Syr. q. s. M. ft. pil. viii.: one every three hours for two or three days. Monesia is highly esteemed by some as a remedy for haemoptysis : R. Mone- sia, Con. Rosar, aa. gr. xv. M. Div. in pil. x. : two every two hours during the day. Where there are inflammatory symptoms and much excitement present, tartarized antimony, com- bined with nitre, as in the following formula, will be found, according to Dr. Cheyne, supe- rior to all other remedies. R. Ant. et Potassa Tart., gr. j.-ij.; Potass. Nitrat., 3 ij.-iv. M. Div. in pulv. iv.-viij., sig.: one every hour. Ipecacuanha is highly praised by Dr. Graves, in doses of two grains every fifteen minutes, or half hour, till the bleeding stops ; and several physicians, in extensive practice in this city, place more reliance on it, either in nauseating or emetic doses, than on any other remedy.* Dr. Chapman thinks that ipecacuanha, given in emetic doses, " wdl do more than anything else" in arresting haemoptysis, and states that he has employed it with increasing confidence for more than thirty years. He attributes its efficacy, not only to the influence which nausea itself has in repressing the force of the circula- tion, but to its general controlling effect over the capillary vessels, modifying their condition, and thus checking the escape of their contents. For cases illustrating the great success of this remedy, see " Lectures on Eruptive Fevers," &.C., Phil., 1844, p. 190, 91, 92. Combined with the acetate of lead and opium, it often proves more efficient than either article separately given. We have no confidence in leeches applied to the hollow of the throat, as recommended by Dr. Graves, unless as a prophylactic measure ; but purgatives are of essential benefit. Most cases of haemoptysis, we believe, are preceded by a suppression of the biliary discharge, which must be restored before we can expect a per- manent suppression of the haemorrhage. In cases of active haemorrhage, attended with a plethoric state of the system, blood-letting, of course, is indispensable; but it should be prompt, and carried sufficiently far as to make a deci- ded impression upon the circulation. Its repe- tition is to be regulated by the exigencies of each particular case. Dr. Chapman thinks that the use of the lancet is not to be restricted to cases only that are marked by fulness and ac- tivity of the circulation with vigour of consti- tution, but that it is an important remedy in removing the topical accumulation, as well as restoring an equilibrium in the circulation. Be- sides, he remarks that in active haemoptysis the lungs are either inflamed or highly disposed to take on inflammation. Cups to the chest, or between the shoulders, are an important part of the treatment, and may often be substituted with advantage for general bleeding.] 137. k. The practitioner is not to rest satis- fied with having fulfilled the first intention—the * [For cases illustrating the utility of ipecacuanha for the suppression of haemorrhage, see " Braithwaite's Retro- spect," Am. Ed., p. 36. 37.J arrest of the hamoptysis; his attention should im- mediately afterward be directed to the removal of any blood that may have collected in the bronchi, and of whatever inflammatory irritation connected with it, either coetaneously or consecutively, that may exist. Where a crepitation is present, and is much diffused through the Ming of one or both sides, more generally of one, fluid is present, and it is either a mucous lymph, or blood, or both, with more or less serum ; the state of the expectoration indicating the pro- portions of either. But the blood may not be expectorated, or may undergo changes pre- vious to expectoration, and clog up the bronchi and air-cells, and either perpetuate inflamma- tory action, or excite it anew. In the slight forms of haemoptysis attendant upon tuber- cles, the effusion of blood is frequently one of the consequences of the inflammatory irrita- tion existing in various parts of the bronchi connected with impaired tone and congestion of parts of the substance of the lungs. Now, by what means is the above consecutive con- dition to be removed! When the attack has been treated actively, the more antiphlogistic means having been employed, and the lungs still remain embarrassed, manifestly from a portion of the effused blood, or from the fluid subsequently exuded, the exhibition of an emet- ic, and the repetition of it, as circumstances may indicate, will prove most serviceable. If febrile action, heat of skin, &c, be still pres- ent, then tartar emetic, ipecacuanha, or both, may be thus employed; but when the vital powers are sunk, and asthenia is very prom- inent, the sulphate of zinc should be preferred. In cases characterized by relaxed, thin, or weak fibres, and general flabbiness of the soft solids, where bleeding would be injurious, emetics are frequently most beneficial. They have been often advised in haemoptysis; but the indis- criminate or inappropriate use of them, and the somewhat empirical recommendation of them by Dr. Marryat, have led to their dis- use. I have, however, often prescribed them with great benefit. This writer directs two grains of the potassio-tartrate of antimony to be first given, and, as soon as nausea com- mences, two grains of sulphate of copper, dis- solved in a little water. He deprecates blood- letting, and, after the sickness has gone off, gives twenty drops of the balsam of copaiba, night and morning, for several weeks, to pre- vent a return of the attack, and the size of a nutmeg, of the following electuary, twice or thrice a day: No. 242. R Pulv. Cinchona! 3vj. ; Sulphuris Sublimati 3iij.; Potassa: Nitratis Jj. ; Oxy-sulphureti Autimonii 3j.; Mucilaginis Acacia;, q. s. ut fiat Electuarium. 138. I have no doubt of this treatment being quite appropriate to many circumstances of the disease; and, even in those cases where inflammatory action may supervene after the haemorrhage has ceased, it may prove benefi- cial, especially if local depletion by cupping; external derivation by blisters, sinapisms, tere- binthinated epithems or liniments, or by issues or setons, and suitable regimen be employed. In order to fulfil the intention stated above, as well as to prevent the return of the hamorrhage, the assiduous adoption of these external irri- tants, the internal use of the balsams or tere- binthinates (F. 18-22), and- an emetic occa- HEMORRHAGE FROM THE RESPIRATORY ORGANS. 107 sionally, to unload the bronchi of accumulated fluids or mucosities, wUl prove most servicea- ble. At the same time, the digestive and ex- creting functions ought to receive due atten- tion, and cough or irritation should be allayed by the combination of narcotics and sedatives, as conium, hyoscyamus, opium, &c.; and of emollients or demulcents, with the above, or other suitable medicines. When the haemop- tysis assumes a periodic form, which rarely is observed, the combination of the sulphate of quinine, with alum or with sulphate of zinc (F. 597, 667), or the electuary just prescribed, ac- cording to Marryat, will generally prove suc- cessful. 139. 1. The inhalation of watery or medicated vapours has been recommended in haemoptysis, and lately employed by both rational and em- pirical practitioners. I have tried several sub- stances, and in various combinations, through this medium. The practice requires much cau- tion ; but I think it will be found often of ser- vice, if discrimination as well as perseverance be observed in respect to it. Towards the de- cline, or in the slighter forms of haemoptysis, the more astringent substances may be used in this way, care being taken that they neither oc- casion irritation or tightness in the thorax, nor excite cough. Those which I have tried in this state are, common vinegar, sometimes with a little camphor, or with a small quantity of tur- pentine ; the pyroligneous acetic acid, crea- sote, and common tar. These were put in an inhaler with hot water, and the vapour inspired in the usual way ; or in a large basin, and hot water poured upon them, and the vapour al- lowed to diffuse itself around the patient. When a terebinthinated epithem or liniment (F. 300, 311) is used, the vapour from it will generally be sufficient. Some time after the haemorrhage has ceased, the cautious adoption of this practice will be serviceable ; and either these or other substances, as benzoin, asa- fcetida, galbanum, myrrh, and other odoriferous resins, or oil of aniseed, may be employed in this way, as directed in the article Bronchi (y 100). In the more asthenic forms of the dis- ease, when the expectoration is copious, or is tinged with very dark blood, the diffusion of the vapour of the above substances in the air of the patient's apartment, and the taking of frequent deep inspirations, will frequently prove benefi- cial. If the patient evince indications of coex- istent or consecutive inflammatory action, emoll- ient vapours (see art. Bronchi, y 76) with the addition of the extract of conium, or of hyoscy- amus, or of stramonium, to the warm fluids employed for inhalation, will be extremely use- ful, especially if cough be severe. 140. C. The regimen, during and after hae- moptysis, is a most important part of the treat- ment.—a. The ancients advised cooling bever- ages and diet. They allowed acid wine, and acerb or acid fruits. The pomegranate was much and deservedly praised by them, on ac- count of its cooling and astringent operation. Glutinous and mucilaginous articles of diet were also recommended. All these deserve adoption. The principal question is as to the diet which should be adopted. Dr. Stewart, some years ago, advised nourishing diet, cold sponging the surface, cold bathing, and exer- cise in the open air, and frequently with ad van-1 tage. To persons of a relaxed habit, with a slow or natural pulse, and to those not suffer- ing from febrile action, this plan is generally appropriate ; very dilute acids, or lemonade, or common vinegar and water, being the usual beverage. He directed the whole surface of the body to be sponged in the morning, and the neck, breast, and shoulders at night, with tepid vinegar and water, gradually reducing the temperature to that of the surrounding air. After the sponging, frictions with flannel or the flesh-brush for half an hour were enjoined. Cold bathing and salt-water bathing were af- terward employed, and continued until recove- ry took place. Dr. Stewart advised this meth- od in both febrile and non-febrile, in acute and chronic cases. In the non-febrile and chronic it is often serviceable, and early in the febrile it may also be occasionally useful. Sponging the surface, and assiduous friction immediately afterward, are applicable to most cases; but the diet requires greater discrimination. Where fever is present, animal food increases the pa- tient's ailments. In those, farinaceous, gluti- nous, or mucilaginous substances only should be allowed, with goat's whey, stale butter-milk, grapes, raisins, the fruit of the carob or St. John's bean, asses' milk, with Seltzer-water, &c. 141. b. The propriety of having recourse to repeated small depletions, or to a moderate blood-letting, about each equinox, in order to prevent the recurrence of haemoptysis, has been insisted on by some writers, and when the ef- fusion depends chiefly upon plethora or active determination to the lungs, the practice may be of service ; hut when it occurs in the prog- ress of tubercular phthisis, it may be injurious, if indiscriminately adopted, although it may be of use in those cases in which subacute inflam- matory action, or congestion of portions of the lungs often complicate the tubercular forma- tions, and occasion the sanguineous discharge. In the more asthenic states, depletions favour the progress of the tubercles, and are more or less injurious. The regulation of the excre- tions ; the restoration of suppressed evacua- tions or accustomed secretions; occasional change of air; residence in a mild, humid, and equable climate ; sea-voyaging; gentle exer- cise in the open air; flannel clothing next the skin ; cold sponging the surface ; acidulated drinks ; light and nourishing food ; mental qui- etude, and the avoidance of whatever depress- es the vital powers, are severally productive of benefit; some of them ought not to be dis- pensed with. Exertions of the voice, playing on wind instruments, venereal indulgences, warm baths, and exposure to vicissitudes of the weather and season, ought always to be shunned. (See art. Tubercular Consumption.) Bibliog. and Refer.—Hippocrates, ntpi vovow. i., p. 451 ; ii., p. 480.— Aretaus, Curat. Acut., 1. ii., c. 2.—Celsus 1. iv., c. 4.—Plinius, Ilistor. Natnralis, 1. xi.,c. 38; 1. xxiv.j c. 7 ; 1. xxx., c. c—Scribonius Largus. De Compos. Medi- cam., c. 21, 83.—Galenus, De Loc. Affect., 1. iv., c 5 • et Method. Med., I. v., c. 13. 15— Aelius, Tetrab. ii.,'serm iv., c. 59.—Rufus apud Allium, Tetrab. i., serm. iii.. c 8~ —Callus Aurehan., Morb. Chron., 1. ii., c. 9, 11.—Marcel- lus, De Med., c. V —Horatius Augenius,t. ii.,1. 11 • t iii 1. 10.—Oribasius, Synops., 1. ix, c. 1,&—Alexander'Trail' 1. ii., c. 6.— Paulus AUgmeta, Opera, 1. iii., c. 31 (See the ,s£ «"' J™"?,10'™?, *"/• Adams' P- m< m- L°ndon, 1834, 8vo).—Marcellus Donotus, 1. iv., c. 19, p 411 _oc lavius Horationus, I. ii., p. 2, c. 9.—Nonnus, c 128 — Actu- artus, Meth. Med., i., p. 17,—Mesut, De .Egr. Pert c 6 108 HEMORRHAGE FROM THE STOMACH. —Rhases, Ad Mansor., ix., 59 ; Continens, 1. ix.—Alsahara- vius, xii., 6.—Haly Abbas, Theor., ix., 26; Pract., vi., 10. —Avenzoar, 1. i., tr. 16, c. 5.—Avicenna, Canon., 1. iii., fen. 10, tract. 2, cap. 1.—Serapion, tr. ii., 25.—Averroes, Col- liget., vi., 34.—Fernelius, Consil., n. 21.—S. Facio, Dis- corso intorno al Sputodi Sangue. Firenz., 1596.—Balloni- us, Cons., i., n. 76 ; ii., n. 52 ; iii., n. 18, 36, 97.—Lienard, Ergo Venus nocet Sanguinis perOs Effusioni. Pans, 1620. —Plater, Observ., 1. iii., p. 786.—P. V. Casiellus, Exerci- tationes Thoracis ad Affectus, 4to. Tolos., 1616.—Alsari- us a Cruce, De Haemoptysi seu Sputo Sanguinis, 4to. Rom., 1634.—Mercurialis, Consil., i., n. 7, 15; ii., n. 42, 68, 95. —Riverius, Cent, i., obs. 83; ii., obs. 52; iii., obs. 12, obs. 11.—Amatus Lusitanus, Cent, ii., cur. 13.—Diemerbroeck, Disput.de Morbis Thoracis, n. 7. Utrecht, 1664.—Zacutus Lusitanus, Med. Pr. Histor., 1. ii., n. 5, 6 ; Prax. Historia- rum, 1. ii., c. 6.—Bennet, Theat. Tabidor., c. 25.—Conring, Diss, de Haemoptvsi. Helmst., 1676.—Bellini, De Morb. Pect, p. 686.—Riedlin, Lin. Med., 1695, p. 54.— Willis, Pharm. Rat., p. 11, sect. 1, cap. 7.—M. Sprewaezer, ^gro- ti Haemoptoisi Consideratio, 8vo. Pragg., 1695.—Mayerne, Praxis, p. 224.—Bonet, Sepulch., 1. ii., sect, v., obs. 13 ; 1. i., sect, ix., obs. 57.—Hoffmann, De Sanguinis Fluxu ex Pulmonibus, obs. 1, 2, 4 ; Opp., ii., p. 207.— Watson, Phi- los. Transact., n. 359.—Hartmann, Nov. Act. Soc. Ups., i., p. 109.—GoW, Compend. Pract., p. 43.—Lentin, Beytrftge, iv., p. 174.—Hasenoehrl, Hist, trium Morborum, p. 96.— Alberti, Diss, de Haemoptysi. Hal., 1730.—/. G. Wagner, De Hsemoptoes Curatione, 4to. Lipsiae, 1742.—J. G. Bren- del. Diss, de Hajmoptysi. Gott., 1747.—Morgagni, De Sed. et Caus. Morb., ep. xxii., art. 4.—Gervasil a Monte Felisco, De Usu Aquae frigidae in Haemoptysi, &c, 8vo. Rome, 1756.—Piderit, Practische Annalen, ii., St., p. 162.—C. T. E. Reinhard, Abhandlung von dem Lungenblutfluss, 8vo. Glogau, 1762.—Lentin, Beytrage, p. 15, 95.—Stoerck, Li- bellus, consequence of active congestion, or of inflam- matory irritation of the villous surface of this viscus, and sometimes also of the parts of thq digestiye tube adjoining it—inflammatory ham* 114 HEMORRHAGE FROM THE STOMACH. atemesis; 2d. That the haemorrhagic discharge frequently arises from interrupted circulation in the spleen or vena porta, or both, and con- sequent congestion of the veins and venous capillaries of the stomach, causing increased action of the arteries, with dilatation of, and consequent effusion from the exhalant pores of the congested surface—congestive sympto- matic hamatemesis; 3d. That the effusion occa- sionally proceeds from diminished or lost vital cohesion of the villous surface, and impaired tone of the capillaries of the stomach, with general adynamia—asthenic symptomatic hama- temesis ; 4th. That, in rare instances, the haem- orrhage arises from an aneurism, from ulcera- tion or perforation of an artery or vein ; and more frequently from malignant, fungoid, or ulcerated tumours in the stomach, or near ei- ther of its orifices, . i., p. 63.—Stoll, Rat. Med., i.. p. 246 ; vol. v.,p. 207.—Thoner, Observ., p. 140.— Marx, Vermischte Boebachtungen, iii., n. 4.— Nauheimer, Diss, de Vomitu Cruento Maxime ab Obstruct, lienis et Atrabile Orto. Mo- gunt., 1775.—Lieutaud, Hist. Anat. Med., obs. 155.— W. Cullen, Works, by J. Thomson, vol. i., p. 288; vol ii., 300. —Lindt, Diss, de Aluminis Virtute Medica. Goett., 1784. —Bang, Auswal ausden Tagebiichern, Ac, Dec, 1787.— Callisen, Act. Reg. Soc. Med. Hafn., ii., ad finem.—Ranoi, Act. Reg. Soc. Med. Hafn., vol.ii., p. 294 ; vol. iv., p. 27. —Strom, in Ibid., vol. iv., p. 285, 288.—L. Loli, Del Morbo Nero, Ossia del Flussn Gastrico Sanguigno, 8vo. Siena, 1788.— Rogery, Journ. Gen. de Med., t. xvi., p. 270.—Sedil- lot, Journ. Gen. de Med., t. xvi., p. 283.—Rosiere, Journ. Gin. de. Med., t. xxvi., p. 139.— Van Doeveren, Diss Ob- serv. Patholog. Anat. Lugd. Bat., 1789— Percival, Essays, vol. ii., p. 181.— Vogel, in Salzb, Med. Chir. Zeitung, 1791, vol. iv., p. 21.—M. Zacchirolli, Della Melene, Ossia Morbo Nero d'Ippocrate, 8vo. Fermo., 1793.-7. P. Frank, De Cu- randis Hominum Morbis, 8vo. Ticini, 1794.— Piderit, Practische Annalen, i. St.. p. 24.— Thomann. Annalen ad 1800. p. 387.—PA. Pinel, Nosograph. Philosophique, t. ii., p. 603.—J. Hamilton, On Purgative Medicines, sixth edit., p. 107.—Dorffmuller, in Hufeland's Journ. der Pr. Ar/.neyk., b. v., p. 832.—Schlegel, in Ibid., b. v., p. 608.—Toggen- iurger. Museum der Heilkunde, b. iii., p. 181, 182.—D G. A. Richter, Die Specielle Therapie, b. iii., p. 311.—P. S. J. Dalche, Essai sur l'Embarras Gastrique, et le Vomisse- mentdu Sang,4to. Paris. 1803.—Thiebalt, Essni sur l'He- matemese. Strasbourg, 1804. — Simon de Machault, Diss. sur l'Hematemese. Pans, 1809.— C. M. Simon, Diss sur. l'Hematemese, 4to. Paris, 1809.—Kortum, Hufeland, und Himly, Journ. der Pr. Heilk., 1810. July, p. 64.—R. Wil- Ian, Miscell. Works, p. 155, 167, 175, 293.—B. Lemonnier, Diss, sur l'Hematemese, 4to. Paris, 1812.— Roeschlaub. Magazm der Heilkunde, b. iv., p. 269.—Batimann, Reports on the Dis. of London, p. 150 ; Edin. Journ., vul. vii., p. 44. j — Osiander, in Salzb. Med.-Chir. Zeitung., 1810, iii., I 191.—Chichester, Med and Surg. Journ. of Edinbugh. vol vii., p. 326 (Larva voided by Stonl).— W. Cooke, in Ibid. vol. ix., p. 299—C. H. Parry, Elements of Pathology am Therapeutics, vol. i., p. 128.—Pinel, Diet. d«s Sc. Med. art. Htmaltmesc, t. xx. Paris, 1817.—Sheridan, On thi Use of Ipecacuan. Emetics, Trans, of Irish Coll. Phys., I iv., p. 42.—Broussais, Hist, des Phlegmasies Chroniques t. ii.. p. 143.—Schmidtmann, Obs. Med., t. iii., p. 1, 6i.—J M. Good, Study of Medicine, vol. ii., p. 451.—C. F. Tach eron, Recherches Anat. Patholog'. de la Med. Pratique, t | i., p. 417, et seq.—Chomel, Diet, de Med., t. x. Paris, 1824 —if. L. Rostan, Traite Elementaire de Diagnostic de Prog nostic, t. ii., p. 485.—M. Gaube, in Revue Med., t. i., p 394, 1825.—/. Johnson's Med.-Chir. Review, vol. ii., p. 481 Ibid., vol. iii., p. 240; Ibid., vol. viii., p. 512; Ibid., vol xiv., p. 548; and Ibid., vol. iv., p. 928 (Ann. Ser.).—J. J Leroux, Cours sur les Generalities de la Medecine, t. ii.,p 23, 26.— Wanderbach, Journ. Univers. des Sciences Med.. Jan., 1828 (Harmat. caused by a leech in the stomach).—M Rullier (by erosion of a branch of the stomachic coronary artery), Archives Generates de Medecine, t. xxiii , p. 137. —Goeppert (ulceration of the stomach, and erosion of tht coronary artery), in Ibid., t. xxvi., p. 414.—J. Elliotson, Med. Gazette, vol. ix., p. bii.-w-Watson, On Hamorrhage from the Stomach. Med. Gazette, vol. x., p. 433, 465.—M. Rullier, Journ. des Progres, Ac, 2d ser., t. iii., p. 250.— Mackintosh. Practice of Physic, vol. i.. p. 186.—E. Ricard, in Journ. Hebdom. de M6d.. t. vii., p. 274.—dimming, Lan- cet. No. 531.—F. G. Boisseau, Nosograph. Organique. t. i., p. 277.—A Bompard, Traite des Maladies des voies Diges- tives, p. 220, 547.— Marten Solon, Dirt, de M«-d. Prat., t. ix. Paris, 1833. — Goldie, Cyc. of Pract. Med., vol. ii. Lond., 1833.— W. P. Dewees, Practice of Phvsic, vol. ii., p. 745.—E. F. Dubois, Traite de Pathologie Generate, p. 41. —C. W. Graham, Edin. Med. and Surg. Journ., vol. xliv., p. 348. [AM. Bibliog. and Refbr.—See Bib. of "Haemorrhage" and ''Haemorrhage from the Lungs."] VII. HEMORRHAGE FROM THE INTESTINES AND Mel.«na.—Syn. Intestinal Hamorrhage, Me- lana, MeAntvo, MfXatva Novaof 'I^eoc, a'tfia- rirrjc, Hippocrates ; Morbus Niger, Auct. Lat. var.; Fluxus Spienicus, Gordon ; Dysen- teria Splenica, Ballonius ; Nigra Dejectiones, Schenck; Secessus Niger, Hoffmann; Me- lana Sauvages, Sagar, Good ; Melanorrhagia, Swediaur; Schwartze Krankheit, Schwartzer Blutfluss, German ; Maladie Noire, French; Melena, Italian. Defin.—The evacuations from the bowels, con- taining fluid, grumous, or coagulated blood, or presenting a black or pitchy appearance, with or without vomiting of blood. 184. I have considered melaena in connexion with intestinal haemorrhage, although the blood colouring the evacuations proceeds, perhaps, as frequently from parts above as from those below the pylorus : it may even come from the mouth, nares, or fauces, or from the respiratory passages, as I have already shown. The me- laena of Hippocrates was the morbus niger no- ticed above, or a variety of haematemesis (v 156); the application of the term melaena chiefly to black-coloured dejections being of modern date, and I believe justly ascribed to Sauvages. I have viewed it according to this acceptation, and connected it with intestinal haemorrhage, as it always arises either from this source or from blood which has passed into the intestines from parts above the pylo- rus. At the same time, the frequent associa- tion of melanoid stools with vomiting of blood, in any of the states above described, has been kept in recollection, and considered as a result of the pathological conditions, causing the san- guineous effusion either in the stomach, or in the small intestines, or even in parts above the former viscus. Indeed, melaena may occur not only in any of the circumstances in which haematemesis has been shown to supervene but also in some of those connected with the HEMORRHAGE FROM THE INTESTINES—Pathology. 119 other haemorrhages already noticed. This fact is fully demonstrated by observation, and by the writings specified above, as well as by those referred to at the end of this article. Melaena may also appear in the course of ca- chectic maladies, especially scurvy, purpura, jaundice, &c. ; or of adynamic or malignant fevers; or of malignant adventitious produc- tions. In order to arrange the various condi- tions in which blood is voided from the bowels, unconnected with haemorrhoids, I shall notice, 1st. Intestinal hamorrhage, the stools not exhib- iting the melaenoid appearance ; 2d. Melana, in relation to the sources of haemorrhage, and to its complications. 185. i. Intestinal Hamorrhage, the stools con- taining fluid or coagulated Blood, or Simple In- testinal Hamorrhage—Hamor. Intestinorum—H. Intcstinalis—occurs, 1st. From interrupted or impeded circulation through the liver ; 2d. From congestion and loss of the vital tone of the capillaries of the mucous coat of the intes- tines ; 3d. From ulceration of the intestinal tunics; and, 4th. From inflammatory irritation, or its consequences in these tissues. A. Intes- tinal haemorrhage, perhaps, most frequently arises from impeded circulation through the vena porta. Even when other pathological states seem to produce it, this may be a concurrent cause : hence, all those lesions of the liver that occasion some impediment to the portal circu- lation may be connected with it. It has also been seen complicated with enlargement and induration of the pancreas, with engorgement of the spleen, with tumours about the root of the mesentery, and with enlargement of the mesenteric glands. These latter lesions are, however, rather contingently associated with the haemorrhage than concerned in the pro- duction of it; whereas, those alterations—as induration, atrophy, scirrus, enlargement, and tubercular or other changes of the liver, which impede or obstruct the circulation of the vena porta, are the efficients of the sanguineous ef- fusion : hence the occurrence of intestinal haemorrhage, not only in the course of these lesions, but occasionally also in connexion with ascites or anasarca ; or even with haemateme- sis, or after protracted intermittent or remit- tent fevers. In these cases, the blood is exu- ded from the intestinal mucous surface, as first inferred by Glisson ; and it is either fluid, gru- mous, or coagulated, and of a venous or very dark hue, as it is changed by the intestinal gases and secretions, or by its remora in the bowels. The appearance of the blood also va- ries according to the situation in which it is exuded. 186. B. Impaired vital tone of the intestinal mucous surface, and of the capillaries supplying it, with congestion or engorgement of those vessels, is also a frequent cause of intestinal haemorrhage. It is owing to this pathological condition that blood is discharged from the bowels in purpura, in the early course of fe- vers, in scurvy, and in other cachectic mala- dies. In fevers, however, there is probably more or less active determination to this part of the economy, especially in those cases in which the haemorrhage occurs early, or in which it proves critical. When it takes place in the course of petechial, putrid, or malignant fevers, it is generally passive, or entirely de- pendant upon the pathological conditions under consideration. In these cases, the blood dis- charged is generally fluid and grumous, and is of a venous or dark hue. When it is evacu- ated in an early stage of continued fever, or is critical, it is sometimes partially coagulated, or coagulates loosely after it is passed. 187. C. Ulceration of the intestines frequently occasions hamorrhage.—The discharges of blood from the bowels in the advanced or latter sta- ges of dysentery or chronic diarrhcea, and of continued fever, are often owing to this cause, although they may also proceed, in these stages of fever, from the pathological states just men- tioned (v 186). Intestinal ulceration unattend- ed by fever may also give rise, although rarely, to haemorrhage. Instances have even occurred in which ulceration had gone on to perforation of the intestine, and adhesion of it to an ad- joining viscus, the consequent haemorrhage proceeding from the ulceration in that viscus. M. Rayer met with a case in which the duo- denum and transverse colon were perforated and adherent to the liver, the ulceration in this latter organ having divided-two branches of the vena porta, and occasioned fatal haemorrhage. 188. D. Inflammation of the bowels is rarely attended by haemorrhage to a great amount, unless it terminate in ulceration. It some- times, however, gives rise to discharges of blood, especially when the caecum or colon is affected, or when portions of the intestines are introsuscepted. It has been supposed by some writers that blood may be discharged from the liver along the ducts; but of this we have no satisfactory proof, and it is certainly by no means probable that this fluid will be passed from the secreting structure of this organ. 189. The appearance of the blood effused from ulcerated vessels depends upon their seat and size, and upon the nature and stage of the antecedent disease. In far advanced cases of fever or dysentery, the blood is generally fluid, or grumous, and dark. When a large venous branch has been ulcerated, and the haemorrhage has been very copious, large soft coagula, with much sanguineous serum, are generally passed by stool. In the inflammatory states of intes- tinal haemorrhage, as in the early stages of acute dysentery, the blood is fluid, mixed with lymph and mucus, and not in very large quan- tity, unless ulceration has occurred. The blood discharged furnishes no sure indication as to the seat of the effusion. When, however, it is fluid and unmixed with faecal matters, the lower bowels are probably the seat. The ancients supposed that if the blood passed before the faecal matters, it proceeded from the lower parts of the bowels ; and that if it was voided after the faeces, it was effused by the upper parts ; but this is no sure criterion. When the haemorrhage is profuse, the blood acts as a cathartic, occasions severe colicky pains, and is often the only substance evacuated. When it is very dark and grumous. or consists of small coagula, and of a sanious fluid, it has generally either been long retained, or been poured out in the upper portions of the canal. The appearance, however, very much depends upon the states of the vascular system, and of the blood itself at the time when the haemor- rhage occurred ; for, if it take place in the lat- ter stages of adynamic or malignant fevers, 120 H.EMORRHAGE FROM THE INTESTINES—Causes. the blood evacuated will be fluid or grumous, j as well as of a dark hue, or otherwise altered. 190. ii. Melana in relation to its sources and complications.—When blood either flows into the stomach from any of the situations noticed above, or exudes from the internal surface of this viscus in so gradual a manner, or so slight a degree as not to excite vomiting, but passes into the pylorus, and when it is exhaled from the internal surface of the duodenum or small intestines, the evacuations often assume a per- fectly black colour, and tar-like consistence. In haematemesis the stools frequently have this appearance (v 163), owing to the passage of a portion of the extravasated blood into the bow- els. This colour is manifestly owing to the admixture of the blood with the biliary and in- testinal secretions, and to the action of the acid and gaseous matters contained in the digestive canal, although other explanations have been advanced (Y 192, 193). Indeed, the evacuations often present, in nearly the same states of constitutional or visceral disease, eve- ry variety of colour and appearance, from those just described as constituting melaena to those resulting from the manifest and abundant pres- ence of pure or venous blood. Evacuations, more or less obviously sanguineous, must be referred either to some one of the sources just noticed, or to the passage of blood from the stomach into the intestines. When the blood comes from parts above the pylorus, the stools generally have more or less of the melanoid Character, and there frequently is, or has been, haematemesis ; but when it proceeds from the parts below, the stools vary with the quantity of blood effused, and other circumstances, and are generally as described above. 191. Hoffmann first, and Morgagni after- ward, attributed melaena to the discharge of blood from the over-distended and ruptured venous capillaries of the intestines, caused by obstruction of the portal circulation and of the spleen. Dr. Cullen considered this to be the usual origin of the disease; but admitted that a true atrabilis might be form- ed, and occasion all the phenomena attend- ing sanguineous melaena. Dr. Good compri- sed, as a species of this malady, that morbid state which has been called green or black jaundice, and which is very different from me- laena, and not necessarily connected with it, although the stools often have a dark green or blackish hue, owing to alteration of the bile, probably from torpor of the liver and prolonged retention of this secretion in the biliary passa- ges. (See art. Jaundice.) 192. While Hoffmann and Cullen attributed the colour of the dejections to the remora and alteration of the blood previous to effusion from the venous capillaries, Portal, Bichat, and others supposed that, in consequence of the impeded or obstructed circulation through the mesenteric and portal veins, the blood was more strongly determined to the extreme arte- rial capillaries or exhalants of the intestines causing distention of, and effusion from these capillaries; and that the change in the blood from an arterial to a black hue was produced subsequently to the extravasation by the acids and gases in the digestive canal. In opposition to these opinions, Dr. Ayre has contended that both melaena and the black variety of haemate- mesis (v 156) arise from the passage of blooc from the minute ramifications of the vena porta in the secreting structure of the liver conse- quent upon extreme congestion of these ves- sels ; a very dark blood, instead of bile, passing by the biliary pores into the hepatic ducts, ant thence into the duodenum. This hypothesis is, however, not supported by pathological re search, and is almost as difficult to refute as tc establish. If all cases of>melaena were pre- ceded by manifest congestion and its conse- quence, more or less fulness or enlargemenl of the liver, the probability of this being the source of melaena would be much stronger than it is; but indications of congestion or of en- largement of this viscus are not uniformly ob- served. 193. Cases sometimes occur in which a verj dark, black, or greenish-black bile is passed, the stools being fluid, or of the consistence of treacle, owing to the circumstance just alluded to, and more fully explained in the article on the Gall-bladder, &c. I have met with such instances connected with chronic disorder of the respiratory and digestive functions. Cases, also, are rarely seen in which melanotic mat- ter is voided by stool, owing to the breaking down of tumours or adventitious encysted for- mations containing this matter, as admitted by Dr. Marcard and Dr. Goldie, or to the exuda- tion of this matter from the follicles where it may have been secreted, if, indeed, such an occurrence ever takes place. In order to dis- tinguish between melaena arising from the effu- sion of blood, or from black bile, or from melano- sis, the stools should be diluted with water, or with a weak solution of soda, when blood will become apparent if the black colour of the evacuations have depended upon this cause. 194. Sauvages and Portal have distinguish- ed as many varieties of melana as there are cir- cumstances in which it presents itself. The latter of these pathologists has illustrated an interesting memoir on the subject by numerous cases ; but the varieties adduced by him are deserving of notice, chiefly as indicating the pathological states on which this morbid con- dition is contingent, and not any modification of this condition itself; for, as he admits, the matters voided are nearly the same in all. The excretion of black or melanoid stools are, ac- cording to M. Portal, met with as follows: a. In the advanced course of continued fever; b. In connexion with periodic fevers; c. After strong mental emotions ; d. After the suppres- sion or cessation of haemorrhoids, of the menses, or of any accustomed discharge ; e. From irreg- ular, suppressed, or misplaced gout; /. In the course of scurvy, whether depending upon en- gorgement of the liver and spleen, or upon alter- ation of the blood ; g. In dropsy, owing to the as- sociated visceral disease, or to the abdominalef- fusion, or to both. This enumeration is, howev- er, defective, inasmuch as the frequent depend- ance of melaena, h. Upon disease of the liver, spleen, or pancreas, unconnected with scurvy or with dropsy ; t. Upon carcinomatous, eneeph- aloid, or fungoid productions in some part of the digestive canal; and, k. Upon tumours devel- oped in the mesentery, has been overlooked in it 195. iii. Causes—a. The remote causes of haemorrhage from the intestines and of melae- na are not materially different from those that HEMORRHAGE FROM THE INTESTINES—Symptoms, etc. 121 occasion hamatemesis (c) 157, 158). Sedentary occupations; intense or prolonged anxiety, and close application to study or business ; full diet and neglect of exercise in the open air; fre- quent contrarieties ; an irritable temper, espe- cially in the melancholic, or sanguineo-melan- cholic temperament; the intemperate and dai- ly use of spirits or other intoxicating liquors ; general debility and cachexia; and the period of life between forty and sixty, are the most common predisposing occasions of the disease. —b. Violent mental emotions, particularly fits of anger ; great excess in eating or drinking ; irritating or drastic purgatives, and acrid poi- sons ; the suppression of sanguineous evacua- tions or accustomed discharges ; the visceral and constitutional maladies just mentioned; and the causes generally productive of haemor- rhage, are the common exciting causes of intes- tinal haemorrhage. 196. iv. The Symptoms connected with me- laena and discharges of blood from the bowels have been partially adverted to (v 189). There have commonly been disorder of the digestive canal, as loss of appetite, nausea, or occasional vomiting, and indications of visceral disease, for a considerable time before the attack. A sallow, dusky, waxy, or leaden hue of the countenance ; a foul, loaded, dark, or otherwise morbid state of tongue, and tainted breath ; a soft or spongy state of gums ; fulness, tension, or griping pains of the abdomen, or fulness or enlargement in the hypochondria; oppression or anxiety re- ferred to the praecordia or epigastrium ; great debility, faintness, sense of sinking, or syn- cope ; flatulence or nausea; and a tensive or dull pain in one or other of the upper abdomi- nal regions; sometimes vomiting of blood ; ver- tigo and coldness of the extremities ; tormina, or colicky pains in the abdomen; and a weak, soft, or open, sharp, or bounding pulse usually recede and usher in the discharges of blood y stool, or tar-like evacuations. In some in- stances, the motions are fcetid or extremely offensive; and in all the exhaustion is great. In a few cases, the quantity of blood passed from the bowels has been small; yet a fatal termination has occurred, preceded by tormina, and by fulness or tension of the abdomen. In these the haemorrhage has been concealed, the bowels being found, upon dissection, filled by semifluid or coagulated dark blood. 197. v. The Diagnosis of intestinal haemor- rhage and melaena is often difficult; first, as re- spects the seat of effusion ; and, secondly, as re- gards the resemblance to other affections, par- ticularly biliary disease and haemorrhoids.—a. As to the source of haemorrhage, the practition- er will be guided in forming his opinion by the circumstances already stated. He will take into consideration the probability of the blood having been poured out from parts above the diaphragm or pylorus, and the existing indica- tions of such visceral disease as usually give rise to sanguineous effusion from the digestive canal.—b. If the colour of the stools be caused by black or morbid bile, dilution with water will impart to them a yellowish, greenish, or greenish-yellow hue. If it proceed from the matter of melanosis, dilution will give them nei- ther a bilious nor a sanguineous tint. When the melanoid appearance depends upon blood, the •tools are generally offensive, and the san- 16 guineous hue becomes very apparent upon dilu- tion.—c. Intestinal haemorrhage is often mista- ken for internal haemorrhoids ; but it is readily distinguished from the latter by the history of the case ; by the tormina and spasmodic pains ushering in the attack; by the action of the bowels being unusual as to the time, and by the attendant sensations and symptoms ; by the faintness and exhaustion attending it; by the existing evidence of visceral or constitutional disease ; and by the imminent danger in which the patient is manifestly placed. Whereas hamorrhoids are accompanied by the usual tu- mours, or by prolapsus of the inner coats of the rectum at stool, along with the tumours; and are generally followed by relief of most of the uneasy symptoms, the haemorrhage occur- ring chiefly when the patient is passing his usual evacuation, which is commonly more or less faecal, or unmixed with the blood which is discharged. 198. The appearances on dissection are nearly the same as are seen in fatal cases of hamateme- sis (y 165). The liver and spleen usually present structural change, and occasionally also the mesenteric glands, the pylorus, and pancreas. Congestion, dark-red, brownish, or purplish patches, ulcerations, excoriations, &.C., of the di- gestive mucous membrane, are often observed, especially when the haemorrhage occurs in an advanced stage of Fever (y 51), in scurvy, or in purpura. In these, the mesenteric and portal veins are very generally loaded with dark fluid or thick blood. In some instances, however, the digestive canal is not materially altered ; and in others it is unusually pale and bloodless. The blood itself is often manifestly changed, the haemorrhage, as well as the melanoid state of the stools, depending partly upon this circum- stance, and partly upon the lost tone of the di- gestive mucous surface and capillaries. This change obviously obtains in the diseases just mentioned, and in scorbutic dysentery, in which discharges of dark blood frequently take place from both the small and large intestines. 199. vi. Prognosis.—Intestinal haemorrhage and melaena are generally attended by danger ; but much depends upon the pathological states of which they are consequences, upon the amount of the discharge, and the consequent exhaustion. When the effusion takes place early in fever or dysentery, is moderate, or is likely to prove critical, a more favourable opin- ion may be given; but with some reservation, nevertheless, When sanguineous or black stools are consequent upon haematemesis, or upon haemorrhage from parts above the dia- phragm or pylorus, the prognosis will have strict reference to the related circumstances, and es- pecially to the parts from which the blood ap- pears to have directly proceeded, and will be either favourable or unfavourable accordingly • but, unless when the blood has come from the lungs, in the manner noticed above (Y 99), or in some alarming states of haematemesis, or when there are very obvious visceral disease, and great exhaustion, the danger is much less than in true intestinal haemorrhage and melaena. 200. vii. Treatment.—The stools ought to, be attentively examined, in those diseases es- pecially in which intestinal haemorrhage and j melaena are most likely to occur, and still more | particularly whenever faintness or exhaustion- 122 HEMORRHAGE FROM THE URINARY ORGANS. after a motion is complained of. For want of this precaution, haemorrhage from the bowels has been often overlooked, and even fatal .syn- cope has supervened soon after the patient has been allowed to get upon the night-chair. In most circumstances of disease in which this form of haemorrhage is apt to occur, a bed-pan ought to be used, and the sitting or erect pos- ture should not be assumed until it is allowed by the physician. 201. A. The ancients supposed that blood effused in the intestines soon becomes putres- cent ; and they, therefore, prescribed purga- tives to carry it off, and to prevent its injurious effects upon the system. This view of the matter is not without truth ; but purgatives ought to be employed with caution, as they are apt to increase the haemorrhagic state of the bowels if they be of an irritating or relaxing kind. Rhubarb, with ipecacuanha and the hy- drargyrum cum creta, and spirits of turpentine with castor oil, are the most safe, appropriate, and efficient purgatives in this disease ; but they will often require to be assisted by muci- laginous enemata, or by injections containing these oils. When the liver is much affected, occasional doses of calomel may be given with rhubarb, or with opium or some other narcot- ic, as circumstances may suggest. The spirit of turpentine was prescribed first by Dr. Adair for this form of haemorrhage, and afterward by Dr. Brooke, in the same year that it was em- ployed by myself, in a different quarter of the globe. I have since always resorted to it, and in some very hopeless cases. In a very severe case of melaena, which I saw in 1823, with Mr. Churchill, this medicine was successfully ad- ministered after the most powerful astringents had failed. It has likewise been recommended by Dr. W. Nicholl and Dr. Elliotson. It ex- erts either an astringent or a purgative effect chiefly, or both, according to the dose and the mode of exhibiting it (Y 176). It is also very beneficially applied over the abdomen in the form of liniment, or of warm epithem or foment- ation. 202. The other means of cure should entire- ly depend upon the related pathological states, and upon the nature of the malady on which this is contingent. If it occur in the course of putro-adynamic fever (v 570), the means there advised should be employed ; if in the progress of scurvy or purpura, the remedies directed for these diseases, in addition to those now sug- gested, ought to be prescribed. If intestinal haemorrhage depend upon structural change of the liver or spleen, the treatment is not mate- rially different from that advised for hamateme- sis in similar circumstances ; but when the dis- charge is profuse, astringents must, in the first instance, be decidedly employed. Of these, the oleum terebinthinae; the acetate of lead with opium, or with acetic acid and morphia; the gallic, citric, or other vegetable acids ; the min- eral acids and the metallic salts ; the chlorides, especially the chloride of lime ; creasote, and the most powerful vegetable astringents should be preferred. When nervous symptoms are present, camphor may be conjoined with either of these, or with opium ; and when the erases of the blood, as well as the vital cohesion of the tissues, are manifestly impaired, the chlorides, or the muriate of ammonia, or the nitrate or the chlorate of potash, &c, may be given with such of the astringents as are congruous with them. 203. B. The diet and regimen should be even more rigidly attended to than in haematemesis. The former ought to consist chiefly of farina- ceous and mucilaginous substances. Fruits and slops are generally prejudicial. Vermicelli, or rice boiled to a pulp, and moistened with beef tea or veal broth, is generally suitable. Per- fect quiet of body and mind, and the recumbent position, ought to be maintained. Wine is sometimes necessary, especially in circumstan- ces requiring the use of opium. Lime-water, alone or with milk, alum-whey, lemonade, im- perial, or any of the beverages prescribed in the Appendix (F. 588, et seq.), may be employ- ed as the patient's drink. When blood has en- tirely disappeared from the stools, attention ought to be carefully directed to the excretions and the digestive functions, and the strength restored by mild and light nourishment, the quantity of which should be gradually increas- ed to a very moderate amount. The causes and pathological states on which this affection depends ought to receive attention, as the re- moval or mitigation of these is the most sure means of preventing a recurrence of the attack. When convalescence is not retarded by disease of the liver, then wine, with seltzer-water, the preparations of bark, and various tonic astrin- gents may be allowed; but the bowels ought at the same time to be duly regulated. See, also, the Treatment of Hamatemesis (y 174). Bibliog. and Refer.—Hippocrates, nep! vovotavA. ii., Opera, ed. Foesii, p. 486.—Aetius, Tetrab. iii., serm i., cap. 46.—Amatus Lusitanus, Cent, vi., cor. 32.—Zacutus Lusitanus, Med. Pr. Hist., 1. ii., obs. 26.—Riedlin, Millena- rius, n 4(11, 517, 742. 996.—Bierling, Advers. Curios., obs. 21.—Bonet, Sepulchretuin, 1. iii., sect, xi., obs. 37.—Pelar- gus, Med. Jahrg.. iii., p. 734; iv., p. 302.—F. Hoffmann, Opera, t. ii., p. 214: et Supp., t. ii., 2.—Lentin, Observ. Med., fasc. ii., p. m.—Adair, in Med. Facts and Observ., vol. iv.. n. 3.—Perotti, in Rarcolta d'Opusooli Scientifici, Ac, t. xvi., p. 245.—Banyer, in Philos. Trans., vol. xiii., n 2.—Bang, in Acta Reg. Soc. Med. Havn., vol. i., p. 18 ; vol. iv., p. 142— Callisen, in Ibid., vol. ii.. p. 331.—Tissot, Epist. Med. Pract.; Ep. ad Zimmermann. 12mo. Lausan, 1782.—Home, Chir. Exp. and Hist., p. 127.—Marcard, Edin. Med. Comment., vol. iv.. p. 203.—Vogel, in Salzburgher Chir. Med. Zeitung, 1791, b. ii., p. 235.—Portal, Mem. sur la Nat et le Traitement de Plusieurs Maladies, t. ii., p. 189 : et Observ. sur la Nat. et le Traitement des Maladies du Foie, p. 530.—Michaelis. in Hufeland, Joum. der Pract. Heilk., b. xii., st. 4, p. 50; and in Richter's Chirurg. Bib- lioth., dish pink urine without blood is generally clear. A mixture of urine and blood tinges a piece of white rag dipped into it of a red colour. Dr. Watson observes that, upon boiling urine con- taining blood, a brown coagulum will be form- ed, and that the fluid part will regain the natu- ral colour of urine. When the black hue de- pends upon the presence of bile, it passes to a yellowish or greenish tint upon dilution with water; if it proceeds from blood, a reddish colour becomes apparent, especially if a little sub-carbonate of soda be added. 214. iv. Prognosis.—The prognosis must de' pend chiefly upon the pathological states pro ducing the haematuria. If these consist princi- pally of inflammatory action or irritation, or of active congestion, a severe, although not ne- cessarily a dangerous disease, is indicated. If there be evidence of calculi in the kidneys or bladder, a nearly similar opinion may be form- ed, but much will depend upon the circumstan* ces of the case and the states of associated disorder, particularly of these organs. If hae- maturia occur in aged persons and broken- down constitutions, or if there be reason to infer the existence of malignant or serious oh- ganic change in any part of the urinary passat ges, the prognosis must be very unfavourable. The amount of haemorrhage is in itself rarely fatal, although the retention of coagula in the bladder is always dangerous, and often fatal, from the consequences which result, particu* larly as respects the excretion of urine. When haematuria appears in the course of adynamic; continued, or exanthematic fevers, or in pur- pura, &c, an unfavourable opinion of the result should be entertained. 215. v. Treatment.—a. When bloody urine proceeds from inflammatory irritation or active congestion, or is supplemental of some other sanguineous discharge, and especially when it is attended by severe pain or symptomatic feven, or increased vascular action, blood-letting, and particularly cupping on the loins, or perineum", according to the seat of the chief affection, should be practised. In these, as well as in other circumstances, demulcent diluents, and oleaginous or mild aperients, are more or less beneficial. When acrid substances have caus- ed the complaint, these are especially required; and the almond emulsion, the gums, the de*- coctjon of althaea, the infusion of linseed, &d, 126 HEMORRHAGE INTO THE BLADDER—Treatment. may be abundantly exhibited, either alone or with small doses of camphor, or with paregoric elixir. When the haemorrhage is induced by calculi, local depletions and demulcents, con- joined with the opiates or other anodynes, or these latter, either with the alkaline carbonates, or with diluted hydrochloric acid, according to the state of the urine, the warm bath, and emollient enemata, will generally be of service. 216. b. When haematuria presents a passive character—when it is attended by great debili- ty or vascular asthenia, or supervenes in the course of the maladies already mentioned, cam- phor should be given in considerable doses, with small quantities of opium or acetate of morphia. In such cases, also, the tincture of the sesquichloride of iron, or the balsams or tercbinthinates, particularly the balsam of Peru, copaiba, the Canadian balsam; or the spirits of turpentine in small doses; or the infusion of uva ursi, or of the diosma crenata (F. 231), may be employed, and conjoined with opiates or other anodynes, according to circumstances. Frank advises cold clysters with vinegar, and tonic astringents internally. Dr. Prout found an obstinate case of profuse haematuria yield at last to a combination of colchicum with uva ursi. Where sabulous or calculous formations are concerned in the production of the haemor- rhage, or when the haematuria occurs in the gouty diathesis, this combination, either alone or with the alkaline carbonates, seems very appropriate. If the urine be alkaline, the de- coction of pareira brava, with nitric or hydrochlo- ric acid, will be of service. When the haemor- rhage is so very profuse as to require to be im- mediately arrested, dry cupping on the loins, the warm bath, or warm pediluvia, spirits of turpentine, given internally and administered in enemata, the acetate of lead with opium, creasote, and the other active astringents al- ready mentioned (Y 40, 178), are the most to be depended upon. Mr. Coulson advises alum, with powdered galls and sulphuric acid, to be taken in the compound infusion of roses. [As the pathology of haematuria differs in different cases, so also must its treatment. In itself, it rarely proves fatal, as the register of the Vienna Hospital shows only a solitary instance out of 13,647 cases of the affection. Often indicative as it is of organic derange- ment, it excites apprehension rather from its complication than from anything formidable in the discharge itself. When of a vital charac- ter, it either spontaneously ceases or is readily checked, and seldom proves seriously detri- mental. Where it is symptomatic of an organ- ic cause, our aim is chiefly to be directed to the removal of the original affection. Where there is evidence of local congestion, general bleeding will be indicated, with cups and leech- es over the lumbar region ; slight purging, and demulcents. Dr. Chapman recommends, in ad- dition to these, an infusion of peach leaves, or of the petals of the red rose, as being more effi- cacious than any other articles with which he is acquainted. (Lee. on Hamorrhages, &c, Phil., 1845.) Dr. Dewees also speaks highly of the infusion of the leaves of the red rose (?ss. to oj. water) prepared with boiling water, of which a wine-glassful is to be given every two or three hours. Next to this in point of efficiency, Dr. D. thinka is the extract of rhatany, in 2 grain doses, every two or three hours. Dr. Eberlb extols the muriated tincture of iron, and a com- bination of ipecacuanha and alum (R Pulv Alum 3J. ; Ipecac. [>)j. M. Div. in x. pulv.: one every- morning, noon, and evening). Where the haemorrhage proceeds from the kidneys, diureties, as the nitrates of potash, and other salines, squills, &c, which are so frequently administered, are highly improper. Instead of exciting the kidneys to increased se- cretory efforts, our object should rather be to allay any increase of action, which may be done by opiates, bleeding, cool demulcent drinks, &c. Occasionally we lind haematuria vicarious to haemorrhoidal or catamenial discharges, and at- tended with symptoms of inflammatory excite- ment. Here, after the employment of anti- phlogistic measures, our efforts should be di- rected to bring back the original discharge ; as a general rule, however, so far as we have ob- served, the affection is usually accompanied by some cachexia, or disease of which debility is a leading feature, as typhus fever, chronic gout, and affections of the liver and spleen, produced by malaria. In such cases, the mineral acids, with quinine, galls, tannin, the tinct. ferri mu- riati, alum, and other remedies of this class, will prove the most efficient. If these should not succeed, we may then resort to those of a more powerful character, as arsenic, zinc, or lead. Dr. Prout recommends the acetate of lead, as more efficacious than any other arti- cles of this class. Dr. Chapman recommends the turpentine, and blistering over the lumbar region, the blister, however, being allowed to remain on only long enough to produce simple rubescence of the skin, as strangury would not fail to aggravate the disease. In the south- ern parts of our country, where the affection so often occurs in connexion with derange- ments of the liver and spleen, it will often be found useful to apply leeches over these organs, which will enable us to administer tonic and astringent remedies with greater confidence and freedom. Where renal haematuria is con- nected with the gouty diathesis, colchicum will prove useful in conjunction with the appropri- ate styptic remedies. The carbonate of soda is recommended by Dr. Prout, after meals, in these cases, and the mineral acids at other times of the day. The balsamic and terebin- thinate remedies, he states, have hitherto dis- appointed his expectations. As prophylactic measures, we have found pure air, moderate exercise, a mild vegetable diet, with the infu- sion of pareira brava, accomplish everything that could be expected in such cases.] 217. c. If coagula form in the bladder, the se- rious consequences they usually induce should be prevented as much as possible, by breaking them down by means of a catheter; and by in- jections of tepid water, or other emollient flu- ids, containing a small quantity of the car- bonate of soda, or of potash. This practice has been advised by Desault, J. P. Frank, Home, Larrey. Howship, and others ; and should not be delayed, or partially or negligent- ly adopted. [In these cases, a large-eyed catheter and an exhausting syringe should be employed, by the aid of which and the occasional injection of water, either cold or tepid, the coagula may I be broken down, and removed. If the h*mor- HEMORRHAGE FROM THE UTERUS. 127 rhage be so profuse that the bladder becomes again distended with blood in a very short time, the injection of cold water into the rectum or bladder will be useful; and should this not suc- ceed, from 20 to 40 grains of alum may be dis- solved in each pint of water injected, a reme- dy recommended by Dr. Prout as seldom fail- ing to check the bleeding, even where the cause is malignant disease. " I have never known," says this able writer, " any unpleasant conse- quences follow the use of this expedient, and have seen it immediately arrest the most for- midable haemorrhage when all other means had failed, and when the bladder had repeated- ly become again distended with blood, and al- most immediately after its removal."—(On Stomach and Renal Diseases, &.C., Amer. edit., Phil., 1843, p. 320.)] 218. d. There have been some other means recommended by writers on the disease, but few of them are deserving of notice. Celius Aurelianus advised blood-letting, the injection of astringent fluids into the bladder, and the application of cold epithems to the pubes ; but considered diuretics to be injurious. Syden- ham recommended depletion, and astringents with narcotics ; Buchave and Loeffler, fre- quent doses of ipecacuanha ; Gooch, large doses of opium ; Moyle, Schoenfeld, and oth- ers, the terebinthinates ; Bishop, the decoction of the leaves of the Persian almond ; and J. P. Faber, the application of lead or of its prepara- tions over the region of the kidneys. 219. e. The regimen during and after haema- turia should be directed in conformity with the seat of the disease, and with the principles al- ready developed. The diet should be chiefly farinaceous and mucilaginous, and the bever- ages emollient and slightly astringent. The waters of Bath, or those of Ems and Carlsbad, or of Seltzers and Geilnau, or the factitious waters prepared at Brighton may be tried. When the bowels require assistance, oleagi- nous purgatives, especially castor and olive oil, are, upon the whole, the most appropriate, and may be freely administered in enemata. The patient should avoid riding on horseback or in a carriage ; but, if the latter cannot be dis- pensed with, an air cushion should be used. Bibliog. and Refer.—Aretaus, Acut., 1. ii.. c. 9.— Paulus JSgin., 1. iii., c. 45 —('alius Aurel., p. 572.—At- ehigenes et Rufus, apud Attium, Tetrab. iii., semi, iii., c. 2. 3.—Actuarius, 1. iv., c. 8.— Avicenna, Canon., 1. iii., fen. 19. tract. 2, cap. 20.—Puollamer, Consilium de sang, mictu. Bamberg", 1590.—Ballonius, Cons. I, n. 3.—Saillens, Quaest. Med. Monspel., 1617.— Schenck, Observat., 1. iii., sect, ii., No. 33(1, 254. 257.—Salmuth, Cent, iii., obs. 47.—Rhodius, Cent, iii., obs. 21.—Zacutus Lusitanus, Med. Priuc. Hist., I. ii.. n. 139 ; Prax. Admir., 1. it., nhs. 78.—J. Lommius, Observat. Medicin., p. 280.—Hollerius, De Morbis Interms, 1. i., o. 51.—Forestus, 1. xxiv., obs. 5, fi, 8, 13.—Sydenham, Opusc, p. 699.—J. M. Bertuch, De CEgro mictu Cruento Laborante, 4to. Jen;*, 1083.—Bartholin, Hist. Anat.. cent. iv., obs. 39; cent, v., obs. 90; Ephemendes Nat. Curios., Ac, t. vi., obs. 31 ; t. viii., obs. 57; dec. i., ann. ix, and x., obs. 67; dec. ii., ann. ii., obs. 63 ; ann. vi., obs. 8 ; dec. iii., ann. iv., obs 13.—Riedlin, Lin. Med., 1696, p. 10.—Bartho- lin, Hist. Anat., cent, iv., hist. 45.—Bonet, Sepulchret, 1. iii., sect. 18, ol>s. 1.—J. Moyle, Chirurgie Memoirs, &c, I2mo. Lond , 1708.—Hoffmann, De Hiemorrhngia ex Uri- nariis Viis, obs. 1. opp. ii., p. 237.—Schurig, H*matologia, p. 299.—Cowper, Philos. Trans., No. 222.—Alberti, Diss. de Mktu Cruento. Hal., 1719.—Biichner, Miscell., 1728, p. 1490.—F. A. Brunck, De Mictu Cruento, 4to. Argent., 1740.—Banyer, Philos. Transact., vol. xiii.— Hasselmann, Diss, de HitmaturiA Nephritica, 8vo. Lugd. Bat., 1768.— M Stoll, Rat. Medendi, vol. iv., p. 290.—Bishop, Med. Pacts and Observations, vol. viii., p. 122.—Buchhave, Act. Reg. Son. Med. Havn., vol. ii., n. 34,_p. 320.— G. Byl, De Hematuria, 8vo. Lovan., 1788.—M. Van der Btlin, Diss. de Haematuria, 4to. Lovan., 1784.—W. Cullen, Works, by /. Thomson, vol. i., p. 288; vol. ii., p. 306.—/. P. Frank, De Cur. Horn. Morb., 8vo. Tieini, 1794 ; t. vi., p. 249.— Ph. Pinel, Nosograph. Philosophiqtie, t. ii., P. 617.—Ni colai, De Urina Nigra. Geuev., 1790— Reil, Fieberlehre, I), iii , p. 115.—Loeffler, Beytrage, vol. ii.— Renoull, Journ. Gener., t. xvii.-Horn, Archiv., 1810, July, p. 298.—D. G. A. Richter, Die Spenelle Therapie, b. iii., p. 461.—Gale- azzi, in Comment. Bonon., t. vi., p. 60.—R. Willan, Mis- cell. Works, p. 299.—Desault, Joum. de Chirurgie, t. iii.— H. Latourette, Essai sur PHematurie, 4to. Pans, 1810.— Aran, Essai sur l'Hematune dans les Militaires a Cheval. Par., 1811.—Deguise, Recueil Penodinue, Ac, t. vii., p. 112.—/. B. Laroche, Dissertation sur l'Hematurie. Paris, 1814.—Pinel, Diet, des Sc Med., art. Hematurie, t. xx., p. 234. Pans, 1817. — Author, in Lond. Med. Repos.. vol. xviii., p. 164.—E. Thompson, in Ibid., vol. xviii., p 380.— /. Howship, On the Dis. affecting the Secretion and Excre- tion of Urine. Lond., 1823, p. S3.—A. Marcet, in Med. Chirurg. Trans., vol. xii., art. 4.—/. M. Good, Study of Medicine, vol. ii., p. 452.—W. Prout, On the Diseases of the Urinary Organs, Ac, 2d edit., p. 296.—Raige Delorme, Diet, de Med., t. x. Paris, 1824, p. 570.—/. Johnson's Med. Chir. Review, vol. vii.. p. 145; Ibid., vol. ii., p. 224.—G. F. Boisseau, Nosograph. Organique, t. iii., p. 377, 521.— T. Watson, On Haemorrhage from the Urinary Organs, Med. Gnz„ vol. x., p. 469.—G. Goldie, Cyc. of Pract. Med., vol. iv., p. 366.—Begin and Lallemand, Diet, de Med. Prat., t. ix. Paris, 1833, p. 385.—R Willis, Urinary Diseases and their Treatment. Lond., 1838, p. 168.— W. Goulson, On Dis. of the Bladder and Prostate Gland, 8vo. Lond., 1841, p. 160. [Am. Bibliog. and Refer.—See Bib. of " Ars. Haem- orrhage" and " Haemorrhage from the Lungs."] IX. HAEMORRHAGE FROM THE UTERUS. -- SYN. Sanguinis Stillicidium ab Utero, Ballonius. Hamorrhagia Ulerina, Juncker, Good. Ham. Uteri, Hoffmann. Menorrhagia, Sauvages, Vogel, Cullen, &c. Fluor Uterini Sanguinis, Boerhaave. Hysterorrhagia sanguinea, Swe- diaur. Metrorrhagia, Sagar, Ploucquet, J. P. Frank. Metro-hamorrhagia, Auctor. Blut- gang, Multerblulfluss, Geb'drmutlcrblutflnss, Germ. Perte de Sang des Femmes, Pcrte Rouge, Perte Uterine, Fr. Perdita di Sangue, Ital. Uterine Hamorrhage, Flooding. 220. Defin.—Discharge of blood from the ves- sels of the Uterus, independent of the menstrual evacuation. 221. From this definition it will appear that Menorrhagia, or excessive menstruation, should not be confounded with Metro-hamorrhagia, or uterine haemorrhage. But it should not be overlooked that the former often passes into the latter. Menorrhagia is treated of in the article Menstruation : haemorrhage from the uterus only legitimately falls under considera- tion at this place. Metrorrhagia (from firirpa, the womb, and f>r/yvvpat, I break forth) has been very generally employed to denote this dis- ease ; but it is evident that alfia should be in- terposed, in order to convey the idea attached to this term, and that the name Metro-hamor- rhagia should be preferred.* The division of this subject, adopted by M. Duges and some others, although considered unnecessary by M. Desormeaux, may be here followed with advantage. I shall, therefore, consider uterine haemorrhage as it occurs, 1st. Before puberty ; 2d. During nubility, or before the cessation of the menses -, 3d. At the critical period of life, and during old age; and, 4th. In connexion with the puerperal states, or during pregnancy, and after delivery. 222. i. Haemorrhage may take plaee from the uterus, or in a slight degree from the vulva, * [It were well if the term hypermenorrhea were employ- ed to express the excessive discharge of blood at the men- strual period, and metrorrhagia to designate that which ap. pears at any other epoch than that of menstruation.] 128 H.EMORRHAGE FROM THE UTERUS—Causm. at any period previously to puberty; but this very rarely occurs, unless as a consequence of masturbation, or of premature sexual connex- ion, or of genital excitement. The destructive vice, masturbation, exists much more fre- quently among young females, and is acquired at an earlier age, than is generally supposed even by medical men, children of the age even of two or three years sometimes acquiring it from nurse-maids or from older children. Two or three instances of this have accidentally come to my knowledge. Both at the infirmary for children and in private practice cases of haemorrhage from the female genitals occurring at irregular periods previously to puberty have come before me, as well as instances of pre- mature menstruation, the discharge recurring after monthly intervals ; and, in every case, a strict investigation has led to the inference as to the cause already stated. Precocious men- struation is much more rare than uterine haem- orrhage before puberty ; the latter may be dis- tinguished from the former by the attendant injury to the general health, and loss of the healthy look and complexion : whereas, the former is accompanied by a more rapid growth of the frame, and by other signs of puberty, as the development of the mammae, &c. [Juridical medicine contains in its records occasional instances of haemorrhages from the vulva long before the period of puberty. Dr. Francis has seen three cases, in one of which this sanguineous discharge occurred prior to the completion of the fifth year, and two before the tenth year of age. In one of these the signs of puberty were preternaturally conspic- uous.] 223. ii. From the 12th to the 16th year, in our climate, the female sexual organs are de- veloped so far as to give rise to the menstrual discharge. But the occurrence of this dis- charge at or for some time after the earlier of these years is not an indication of these organs being capable of performing all their functions, inasmuch as impregnation is rarely effected before fourteen years of age. Metro-hamor- rhagia occurring after puberty, independently of the puerperal states, or menorrhagia proceed- ing so far as to amount to a true haemorrhage, is liable to recurrence, at irregular or regular periods. When the haemorrhage is slight, and returns at the monthly periods, the observa- tions offered when treating of excessive Men- struation are altogether applicable But when it is very large, or of frequent or of habitual recurrence, it is most exhausting and injurious to the system, although it may be entirely in- dependent of any structural lesion. A female may experience only one attack, arising from excessive determination of blood to the uterus, caused by various exciting causes ; and, even when the attacks recur, they will be much in- fluenced by diet and regimen. Whenever they return, whether at monthly, at irregular, or at short intervals, or whether the discharge be continued or remittent, especially if the female have been or is married, or has had children, some morbid structure in the uterus should be dreaded, and a careful examination made per vaginam. Uterine haemorrhage at this epoch, unconnected with impregnation and the puer- peral states, is either, 1st. Sthenic or active— depending upon determination of blood, to, or upon inflammatory irritation of the uterus j or, 2d. Asthenic or passive, arising from im- paired tone of the uterine vessels and parietes ; or, 3d. Symptomatic of organic lesion. But before the phenomena ushering in or attending these states of the disease arc described, the causes which induce them may be detailed.* 224. A. Causes.—The predisposing causes which are more especially concerned in the production of this form of uterine haemorrhage are the epochs at which the menses first ap- pear, and at which they altogether cease; the menstrual periods themselves; general or local plethora; excessive sensibility of the uterus, arising either from original conformation, or from inordinate sexual excitement, or mastur- bation ; frequent or difficult child-bearing, or abortions, especially if they have succeeded each other rapidly; constriction of the abdo- men by tight corsets (Maukiceau, Ranoe) ; too much warmth applied to the lower parts of the trunk and thighs; very hot seasons; the habitual use of exciting liquors, of rich and high-seasoned dishes ; and a frequent recourse to warm baths. These predispose chiefly to the more active states of uterine haemorrhage, but the following favour the occurrence of the more passive forms; especially weakness of constitution, general debility, and cachexia; the lymphatic temperament; imperfect or un^- wholesome nourishment; chronic or excessive discharges, particularly prolonged lactation, the depressing passions, as grief, sadness, anxiety, &c.; the abuse of relaxing beverages; [an indolent mode of life; the use of foot- stoves ; the abuse of emmenagogues, of acrid purgatives, and the warm bath, &c] 225. b. The exciting causes are, stimulation of the vascular system generally, or of the uterine organs in particular, by the use of hot baths, of intoxicating liquors, of acrid purga- tives, or of emmenagogues, and by excessive sexual indulgence; riding on horseback, or in an uneasy carriage ; prolonged dancing; run- ning, or walking too far ; lifting heavy weights and physical exertions of any kind; shocks or concussions of the trunk; falls on the thighp or hips; excitation or irritation of the sexual organs, by injections, pessaries, or supposito- ries ; the more violent mental emotions, as an- ger, fright, &c. Sennert refers to a case in which it was induced by a stimulating pessary ; and obstruction or retardation of the menses may be the cause of haemorrhage, independent- ly of any means being used to remove this obstruction, as shown by Desormeaux and Lo- coes. It is, also, not unusual for metro-heem- orrhagia to occur within the first fortnight after marriage, especially when this rite has been performed shortly before the period of female indisposition. It has been supposed that sexual congress during this period is apt to induce an attack of this disease. Certain causes, also, may occasion it, by affecting re- lated organs, and thereby acting sympatheti- cally upon the uterus. Van-den-Bosch adduces * CM. ColombaT makes three divisions, 1. Essential, 2. Sympathetic, 3. Symptomatic Jiajmorrhagcs; the first two classes including all discharges of blood that take place without wound, erosion, or appreciable rupture of tissue , and the latter those which constitute secondary phenomena or accidental complications of some more serious disease.— (A Treatise on the Diseases and Special Hygiene of Fe- males, translated by C. D. Meios, MjD., Phil., 1845, ri. HEMORRHAGE FROM THE UTERUS—Diagnosis. 129 instances of it having been produced by worms in the intestines. I have seen it favoured, if not excited, by ascarides. Stoll and Fincke observed uterine haemorrhages unusually prev- alent during the bilious inflammatory fever of 1778. Gendron, Conradi, Strack, and Hopf- ner remarked it occasionally to attend gastric and bilious diseases; and Ziegert conceived that it is not infrequently induced by irritating matters lodged in the bowels. The irritation of the mammae during suckling causes it in some females. A passive and severe form of the disease has been observed to attend upon epidemics of an adynamic or malignant char- acter ; and upon scurvy, and some other ca- chectic maladies. 226. But however influential and numerous may be the occasional causes of metro-haemor- rhagia, they do not so frequently produce it as morbid formations in the uterus, particularly librous and other tumours seated in the parie- tes of the organ, or under the internal lining, polypous productions, hydatids, moles, ulcera- tions, carcinoma, &c. It may also attend in- version, prolapsus, or other displacements of the womb, or may accompany inflammatory congestion of this viscus, or chronic metritis ; and it may even prove a critical evacuation in these affections. [It may also be the result of scorbutic, eruptive, typhoid, and pestilential dis- eases, and of malignant intermittents.] 227. B. Symptoms and Progress.—These vary with the causes of the haemorrhage. If the oc- casional cause be violent, it sometimes follows instantly upon the action of such cause ; but more commonly a certain interval elapses, du- ring which indications of congestion of the uterine vessels may be observed. In some such cases the attack is so severe as to place the patient's life in jeopardy, particularly if it have occurred during the menstrual period. This form, which may be called accidental ute- rine haemorrhage, does not ordinarily occur; but that, on the contrary, which follows the opera- tion of the predisposing causes is slowly estab- lished, and often by a successive increase or duration, or by the more frequent return of the menstrual discharge. 228. The precursory symptoms of an attack sometimes consist only of uneasiness, or col- icky pains, as on the accession of the menses ; but more frequently the discharge is preceded by some of the following signs: by enlarge- ment, tenderness, or pain of the breasts ; ten- sion at the hypochondria ; a sense of fulness, weight, heat, throbbing, or pain in the hypo- gastric and inguinal regions; constipation, or tenesmus, with occasional abdominal pains; general lassitude, and a frequent, soft, or open pulse. To these succeed pallor of the face, coldness of the extremities, horripilations, the cutis anserina, and heat or pruritus of the gen- itals, followed by the sanguineous discharge, which removes most of the foregoing ailments ; but, when the loss of blood has become great for her strength, the patient complains of a sense of sinking or weakness at the epigastri- um ; and when it is excessive, the lips and face are pallid, the pulse fails, and the eyes grow dim ; noises are heard in the ears, and deaf- ness supervenes ; respiration becomes quick, laborious, or irregular, and faintness, full syn- cope, convulsions, or even death may take " 17 place. But the symptoms do not always follow this course. In some cases the discharge is less rapid or excessive ; coagula form in the vagina, and these restrain the haemorrhage, and are afterward expelled by voluntary efforts be- fore the severer symptoms occur. In delicate or nervous females convulsions or other ner- vous symptoms may appear early or before much blood is lost. Violent headache, especi- ally towards the occiput, is a very common at- tendant, and generally continues long after the haemorrhage has ceased. If the discharge, without being excessive and rapid, recurs fre- quently, or is moderate but continued, or mere- ly remits, the patient complains of pain and sinking at the stomach, of extreme langour and exhaustion ; the pallor is extreme, the eyes are surrounded by a livid circle ; the ankles be- come cedematous, especially towards night; va- rious nervous symptoms appear, and serous ef- fusions into the shut cavities occasionally oc- cur. Metro-haemorrhagia may appear at first in a sthenic or acute form, and become passive or asthenic from its continuance or recurrence, the effused blood being frequently thin, pale, or dark. It may continue long, or return often without giving rise to any severe ailment, or merely to some of the foregoing symptoms in a slight degree. When it occurs at the men- strual period, it is often replaced by a leucor- rhceal discharge. 229. C. Diagnosis.—The disease is so mani- fest as to the extent of the sanguineous dis- charge, and the effects thereby produced upon the system, that its diagnosis is a matter of no difficulty. But it is not so easy to distinguish between the causes which produce it and the states of the economy which are induced by it. Yet this distinction, as M. Desormeaux contends, should be made, as it directs to a ju- dicious method of cure, and it will generally be made without great difficulty if the attention of the practitioner be directed to the subject, and if the various circumstances causing the at- tack, and the several phenomena attending it be passed in review. As to uterine haemorrha- ges dependant upon organic lesions of the ute- rus, it may be remarked that most frequently they are not passive, even when they proceed from ulceration; but that they are generally preceded by circumstances indicating sanguin- eous congestion, active determination, or art haemorrhagic effort. 230. iii. Uterine haemorrhage, about the peri- od of the cessation of the catamenia or subsequent- ly to this period, is not infrequent. Menstrua- tion then often assumes an irregular form, dis- appearing for months, and returning in a pro- fuse or truly haemorrhagic form. Generally this circumstance is unattended by material risk. But if the discharge be very great, or occurs often, or if it appears after the age of fifty or after the catamenia have ceased for many months, or for two or three years or. more, there is sufficient cause for alarm, and serious disease of the uterus should be sus- pected. Such returns of youth, with which aged females sometimes console themselves, are rarely unattended by some one of the struc- tural changes already enumerated Cy 226). I was consulted, however, long ago in a case of a female above sixty, and otherwise in good, health, who had returns of uterine haemorrhage 130 HEMORRHAGE; PUERPERAL UTERINE. at nearly monthly intervals. No disease was detected upon examination, and she is now alive and well, and in her 74th year. I was very recently called to a lady 47 years of age who had been subject to frequent returns of uterine haemorrhage during two years, and who was labouring under a dysenteric attack when I saw her. This latter was soon subdued, when the haemorrhage and the cause of it be- came objects of attention. An examination was made, and a hard fibrous tumour was found in the os uteri. It was soon afterward thrown off; but the haemorrhage returned and symptomatic irritative fever continued. An examination was made some days afterward, and another tumour was found passing into the vagina. This, which was distinct from the former in structure and form, came away soon afterward, and the recovery was progressive and complete. In this case the tumours were most probably developed beneath the internal lining of the uterus, and thrown off in the course of the treatment which was adopted for the ar- rest of the haemorrhage. 231. The symptoms of uterine haemorrhage at this advanced epoch of life are not different from those already described (y 227); but they are more generally caused by organic lesions of the womb than uterine haemorrhage at the preceding epoch, and complicated with the symptoms which more particularly appertain to the associated lesion. Indeed, this constitutes the chief malady, the haemorrhage being only the contingent, but often the more immediately dangerous or most alarming occurrence. The consideration, however, of these associated le- sions cannot be entered upon at this place. It is fully entertained in the article upon diseases of the Uterus. 232. iv. Of Puerperal Uterine Hemor- rhage.—Under this head is comprised haemor- rhage during pregnancy or parturition, and after delivery. The changes that then take place in the uterus, and particularly soon after parturi- tion, sufficiently account for the frequency of metro-haemorrhagia at these periods. During pregnancy there is an actual increase of the vi- tality as well as of the bulk of the uterus : a state of orgasm of which vital activity and vascular determination are the chief elements. Hence the active nature of the haemorrhages that take place from it at this epoch. Besides, this viscus contains an organized and living body, presenting intimate relations with it, and opposing certain of the circumstances which favour sanguineous effusions from it. The vascular connexion between the uterus and placenta becoming more developed as pregnan- cy advances, it follows that the detachment of a portion or the whole of the placenta or ovum will give rise to a more profuse haemorrhage in the advanced than in the earlier months of this period ; but as soon as the uterus has thrown off its contents, and in proportion as the uterus contracts, the disposition to effusion will become less, until it altogether ceases. Haemorrhage during pregnancy or after deliv- ery may proceed either from the numerous minute decidual vessels which connect the ovum to the internal surface of the uterus, and are necessarily torn when the ovum is either partially or altogether separated, or from the semilunar openings seen in the inner surface of the uterus when the placenta is removed, or from both sources. The opinions of patholo- gists are divided on this subject; but as long as the exact offices of these openings are un- determined, no precise inference can be ar- rived at as to this question.* However it may be settled, the treatment to be adopted is un- affected by it, inasmuch as the fact is unques- tioned that it is to the partial or entire detach- ment of the placenta from the uterus that ute- rine hemorrhage, at an advanced period of pregnancy, is generally to be attributed. 233. Previously to the consideration of true puerperal uterine haemorrhage, the disputed topic as to the source of the loss of blood, occa- sionally observed in the earlier months of preg- nancy, may be briefly referred to. This spe- cies of discharge has been considered as a true menstrual evacuation from that part of the uterus to which the ovum has not become par- ticularly attached by means of the placenta, and that it escapes through the imperfectly closed os uteri, owing to the softness of the mucous or albuminous secretion which fills it. But if this were the case, we may reasonably infer that it would also occur in many instan- ces in which the os uteri presents a complete obstacle to its exit, and in which it would ac- cumulate and assume the form of internal haemorrhage. Having met with two or three instances in which I was enabled to inquire into the phenomena attending this kind of dis- charge, I am of opinion that it proceeds from the cervix and os uteri, external to the limits to which the deciduous membrane extends ; and that it depends upon the active vascular determination of which the uterus is the seat during the early months of pregnancy. In some cases this discharge takes place only once, about the usual monthly period ; in others, oftener ; it is generally slight, and of short du- ration ; seldom considerable. It often passes into a somewhat profuse leucorrhoea ; and this circumstance indicates that it proceeds from the same seat, and depends upon a nearly sim- ilar state of vascular action as that secretion. 234. Puerperal uterine hamorrhage is some- what different as to its causes, prognosis, and indications of cure in the different periods in which it occurs: 1st. It may appear before the sixth month of pregnancy, and it is then general- ly active, or dependant upon vascular determi- nation, or a molimcn hamorrhagicum ; it is sometimes mechanical, or owing to a local in- jury or violence, which has occasioned the partial or general separation of the attach- ments of the fcetus, and connected with abor- tion, the risk of which it announces. 2d. Du- ring the three or four last months of pregnancy it may, in some cases, be connected with the same causes or changes; but it more frequent- * [Dr. Robert Lee maintains that, although the par- tial detachment of the membranes from the vicinity of the cervix may occasion a slight oozing of blood from the rup- ture of some small deciduous arteries and veins, yet the quantity proceeding from this source can never be great, or amount to what is usually called a flooding ; that it is from the great semilunar, valvular-like, venous openings in the lining membrane of the uterus, and of the arteries laid open by the separatiou of the placenta, that the blood alone flows in uterine haemorrhage ; that all the different causes of flooding, as blows, falls, shocks of various kinds, mental nnd physical, produce their effect by separating and expo- sing the artenes and veins by which the circulation of the maternal blood is carried on in the placenta.—(Lectures on I the Theory and Practice of Midwifery, Phil., 1844.)! HEMORRHAGE; PUERPERAL UTERINE. 131 ly depends upon the attachment of the placenta upon, or very near to the mouth of the womb. 3d. It is chiefly to this cause, and to some oth- ers about to be noticed, that haemorrhage takes place during parturition; and, 4th. It is gen- erally to imperfect contraction of the uterus that its occurrence after delivery is to be attrib- uted. 235. Besides these divisions, there is an- other to which some attention should be di- rected : this is into internal and external uterine haemorrhage. The former often takes place after delivery at the full time, and after abor- tions ; but its occurrence during pregnancy, and while the foetus and its envelopes fill the uterus, has been disputed. M. Desormeaux observes that, in internal haemorrhage during pregnancy, the blood is effused either between the uterus and membranes, or within the mem- branes. When seated between the ovum and uterus it depends upon the same causes as ex- ternal haemorrhage, but certain circumstances have opposed the discharge of the blood. Al- binos found the placenta detached, and a large quantity of coagulated blood interposed be- tween it and the uterus, its circumference being firmly adherent, and preventing the es- cape of the blood. Baudelocque and Desor- meaux believe that, in rare instances, the ex- ternal discharge may be prevented by the head of the foetus pressing upon the neck of the ute- rus, or by a clot of blood plugging up the os uteri. Haemorrhage occurring within the mem- branes is, strictly speaking, fatal; as the blood in such cases comes from the vessels of the fcetus, and generally from a rupture of the um- bilical vessels. These forms of internal haem- orrhage (during pregnancy) have been denied by M. Duges and some others. But the facts adduced by Albinus, De la Motte, Levert, and Baudelocque indicate that it actually oc- curs but in rare instances. M. Dksormeaux even enumerates the symptoms by which its existence may be recognised. He states that it may be inferred from the presence of the usual symptoms of haemorrhage, without the external discharge ; by a sense of weight and of painful tension in the region of the uterus ; and by the sensible augmentation of the vol- ume of this organ, generally in an unequal or lobulated form, owing to the effusion occur- ring exteriorly to the membranes, and being confined to one part. It is obvious, however, that these indications cannot be fully depended upon. 236. A. Uterine hamorrhage previous to the sixth month of pregnancy arises in the manner already stated, from the causes enumerated above (T 224), or from means resorted to in order to procure abortion, or from some of the other causes adduced in the article Abortion. At this period a certain interval elapses be- tween the action of the cause and the com- mencement of the discharge, during which symptoms indicating sanguineous congestion of, or determination to the uterus are manifest- ed ; and when a suitable treatment is then adopted, these symptoms disappear, and haem- orrhage is prevented. The causes of haemor- rhage, during this part of pregnancy, are nev- er more influential than at the usual periods at which the catamenia would have returned if the patient had not been pregnant; and it is during these months that general or local pleth- ora and mental emotions, causes so frequently concerned in the production of uterine haemor- rhage, seem to be most injurious. 237. B.—a. Hamorrhage at, or subsequently to the sixth month is generally owing to the attach- ment of the placenta on the neck of the uterus, and commonly appears without any obvious re- mote or exciting cause. It is generally mod- erate at first, and either subsides spontaneous- ly or after treatment. But it soon returns as before, is more abundant, continues longer, and does not yield so soon to treatment. Haemor- rhage from this attachment of the placenta gen- erally goes on increasing until the child is de- stroyed, or delivery is effected. Yet it occa- sionally commences with great violence, and instantly threatens the life of the female. Some- times it does not occur until near the natural period of delivery; or it appears much earlier, and returns not until then. M. Duges consid- ers that, when the placenta is attached only partially over the neck of the uterus, or later- ally, the dilatation of the neck will occasion only a slight or very partial detachment of it, and a moderate haemorrhage, admitting of be- ing permanently arrested ; but that, when it passes over a great portion of the cervix and os uteri, the discharge, although moderate at first, will return with greater violence and frequency, and will at last continue until the uterus is emptied, or until the mother and child perish. And, where the life of the female is preserved, the great loss of blood leaves her in a state of anaemia and exhaustion, attended with severe headaches, sleeplessness, or palpitations, and other sympathetic affections. 238. The period of utero-gestation at which this variety of haemorrhage takes place coin- cides with that at which the relation of the pla- centa with the cervix and os uteri, to which it is attached, is disturbed, and which is usually from the sixth to the eighth month. But it may occur early in the fifth, or in the course of the ninth. The discharge appears without any obvious cause ; but it sometimes is hasten- ed by some effort or physical shock, and is even occasionally attended by a sensation leading the patient to infer that something had given way in the uterine region. During labour-pain3 the discharge of blood is always increased, while it is diminished by the contraction of the uterus in other cases ; and, as parturition pro- ceeds, the placenta occasionally passes before the foetus, which generally dies if this process is not speedily completed. Upon examining the os uteri in this form of haemorrhage, it is found thicker and softer than usual, and its or- ifice is occupied, either partially or altogether, by a soft, spongy body, which must not be mis- taken for a coagulum of blood. If a coagulum be detected in this situation, it ought not to be disturbed, lest the haemorrhage be renewed. 239. b. But haemorrhage from the uterus may occur in the latter months of pregnancy, al- though the placenta is implanted on the upper part of the uterus. This, however, is compara- tively rare. The blood may be effused in small quantity, and may be chiefly internal. When it is in considerable quantity, and the placenta is separated to some extent, uterine contrac- tions are exerted, terminating in delivery, or in a renewal of the haemorrhage, from which 132 HEMORRHAGE FROM THE UTERUS—Prognose. the patient may expire. This form of haemor- rhage may occur without any premonitory sign ; but it is more frequently preceded by a sense of uneasiness or weight, or of pain in the re- gion of the uterus, and other signs of conges- tion or of active determination. It is most frequently caused by external injury, fright, and concussions of the trunk. 240. C. During delivery, a small or moderate quantity of blood is lost, but is rarely pure, be- ing always accompanied with water and mucus. When true haemorrhage occurs, it is generally owing to the detachment of the placenta by the unequal contractions of the uterus, or to the situation of the placenta near or upon the os uteri. In rarer cases, it proceeds from rupture of the parietes of the womb, or from rupture of the umbilical cord. In cases of plurality of children, haemorrhage may supervene in the in- tervals between the delivery of each. It is then chiefly owing to effusion from the part of the uterus where the placenta of the first child is inserted, owing to a partial or complete de- tachment of it. When flooding occurs in the first stage of labour, the discharge always ceas- es when the uterus contracts, and returns du- ring the intervals between the pains. 241. D. Hamorrhage after Delivery.—This may occur previously to the expulsion of the placenta or subsequently.—a. When it takes place before the placenta is thrown off, it is usual- ly owing to one or other of the following cir- cumstances, or, at least, it is met with in con- nexion with them : 1st. To torpor of the or- gan ; 2d. To a partial detachment of one part of the placenta and undue adhesion of another; 3d. To irregular or spasmodic contraction of the womb. It scarcely ever proceeds from the cord, unless in cases of twins, when it may possibly take place. But it may arise from la- ceration of the uterus or vagina.—b. After the expulsion of the placenta, flooding generally pro- ceeds from imperfect contraction or torpor of the womb. It may. however, be connected with inversion, or with retention of a portion of the placenta or of the membranes, in the cav- ity or mouth of the organ ; and in a few cases it appears to depend upon active determination of blood to the uterine vessels, as insisted upon by Gooch, after some Continental wri- ters. These states of the uterus, especially flaccidity, may be readily inferred from a care- ful examination and observation of the symp- toms. Whether the haemorrhage takes place before or after the expulsion of the placenta, it may be either internal or external, 242. c. Internal uterine hamorrhage, after de- livery, may thus take place before the expul- sion of the placenta or afterward, or it may be favoured by the retention of the placenta or of the membranes, or of both, partly in the neck and mouth of the womb, and partly in the va- gina. That this form of haemorrhage should be early detected and remedied, is of the utmost importance. The uterus upon external exam- ination will be found soft, roundish, and in- creasing in bulk, so as often to approach, or even to pass the umbilicus. It may even ulti- mately attain the dimensions it had just pos- sessed, and be followed by the death of the female or by a prolonged and difficult recoyery. Whenever pallor of the countenance and lips, vertigo or swimmings, noises in the ears, a sense of sinking, nausea, or retching; a very rapid and irregular pulse, a quick, anxious, or gasping respiration ; restlessness, jactitation, &c, supervene, while the lochia are not more than usually abundant or are diminished, inter- nal haemorrhage to a most dangerous extent may be inferred, and a careful examination of the abdomen ought to be made. In order to ascertain the cause of the retention of the ef- fused blood, the expulsion of all the placenta and membranes should be proved, as well a9 the presence or absence of a portion of these, or of coagula, in the os uteri and vagina. At the same time, distention of the uterus by ef- fused blood must not be confounded with the existence of another child in the womb, or with meteorismus, or with a distended urinary blad- der, either of which cannot be mistaken if at- tention be directed to it, and to the existence of the symptoms just enumerated. 243. d. External flooding after delivery of both the foetus and placenta is not to be mis- taken, if due attention be paid the patient; for the blood may collect and coagulate in the cen- tre of the bed in the depression produced by her weight, and be overlooked, if she be ex- hausted and carelessly attended. This variety of haemorrhage occurs in every degree of se- verity, and is either gradual, draining, and con- tinued, or rapid, violent, alarming, and even speedily fatal; or remittent, intermittent, &c. It is accompanied with all the symptoms al- ready noticed in connexion with this (y 228), and other severe forms of haemorrhage, and is followed by most of the phenomena caused by extreme losses of blood, as described in that article (A 53, et seq.). While internal or con- cealed haemorrhage is almost uniformly depend- ant upon a total want of uterine action, the external form arises either from that state, or from imperfect, irregular, or transient contrac- tions, and from either of these states in con- nexion with vascular determination to the womb. When slight, continued, or draining, it may be kept up by the retention of a portion of the placenta or membranes, or of fibrinous coagula, in the uterus. It is important to keep in recollection these pathological states, as upon them the appropriate use of remedies en- tirely depends. 244. ii. Prognosis. — The circumstances which indicate a favourable or unfavourable result in other haemorrhages also apply to the different forms of uterine haemorrhage. But the condition of the uterus, in both the unim- pregnated and puerperal states, and the period of gestation, with various other related circum- stances, must be considered in reference to particular cases. A. In uterine hamorrhage oc- curring independently of the puerperal stales, the prognosis should entirely depend upon the na- ture of the causes, the states of the uterus, the severity of the symptoms, the duration of the disease, and the strength of the patient. When it is induced by occasional causes of a passing or accidental nature, danger will arise only from the quantity of the discharge. If it pro- ceed from causes which have modified the con- stitution, and endowed it with a tendency to haemorrhage, or occasioned an habitual dis- charge, the treatment will generally prove dif- ficult or unsatisfactory. That variety which occurs in girl* at the periods of puberfy ceases HEMORRHAGE FROM THE UTERUS—Treatment. 133 spontaneously as the menses become regular; and that which takes place at the critical age of woman also disappears with the monthly indispositions, if the womb be free from organic changes. When it proceeds from these chan- ges, the prognosis should be guarded, even when circumstances admit of it not being unfavoura- ble. In these cases, danger may arise from the haemorrhage, as well as from the nature of the lesion of the uterus ; but more frequently this latter is the chief source of risk, unless where the morbid formation admits of removal, as in the case of polypus uteri. (See art. Ute- rus.) 245. B. Uterine hamorrhage during the puer- peral states is often one of the most alarming and speedily fatal of the maladies peculiar to females. According to Puzos, it is rarely fatal before the fifth month of gestation. Experi- ence has shown the justice of the remark ; yet I have seen life in imminent peril at this early period. Flooding is the more dangerous the nearer it occurs to the natural period of deliv- ery, whether previously or subsequently to this process. As respects the foetus, however, the chances of its preservation diminish with the length of the time to the period of birth. Haem- orrhage from insertion of the placenta on the neck or mouth of the womb is always attended by danger, varying with the violence of the dis- charge, and requires the speedy acceleration of parturition to save either the mother or child. Internal is much more unfavourable than exter- nal haemorrhage. The latter, when slight, is often its own cure, by removing plethora or vascular determination. But the former has frequently proceeded to a dangerous or even fatal extent before the medical attendant is made aware of its accession. Moreover, in order to arrest it, the uterus must be emptied of its contents ; and this often increases the exhaustion, or causes a farther loss of blood. In either internal or external haemorrhage, when the pulse becomes very frequent (above 120), small, thready, or irregular; the breath- ing suspirious or gasping; the motions convul- sive, with shudderings, or jactitation; or the sinking and anxiety distressing ; and if full syncope supervene, notwithstanding the supine posture and low position of the head, great danger exists, and the patient may either sud- denly expire, or recover slowly and with great difficulty. 246. iii. Treatment.—A. Haemorrhage from the uterus previously to puberty seldom requires more than moral treatment.—B. When it occurs at or after puberty, independently of the puerperal states, 1st. The occasional causes should be avoided ; 2d. Means appropriate to the patho- logical states producing it ought to be used for its arrest chiefly when it is excessive ; and, 3d. Measures should be directed to prevent its return when the nature of the case indicates that a return is probable. The fulfilment of the first intention will often accomplish the third, and will generally promote more or less the success of the second.—a. In a great ma- jority of instances, the haemorrhage is the re- sult of active determination or of congestion ; and it is often connected with a chronic or slight grade of inflammatory action. In these circumstances, the discharge ought not to be arrested by astringents or tonics; for I have' seen this kind of interference convert a slight and salutary haemorrhage into a severe or chronic inflammation. Yet it is not always judicious to allow the discharge to continue, inasmuch as the uterus might thereby contract a disposition to haemorrhage, or to some other disease. It will be better to attack at once the pathological conditions—general or local pleth- ora, or local vascular excitement—upon which the disease depends, by general or local deple- tions, by internal refrigerants, by a strictly anti- phlogistic diet and regimen, and by repose of mind and body. The patient should be placed in a cool and airy apartment, and preserve the horizontal posture on a bed or couch, which is neither too soft nor too warm. The nitrate of potash, vegetable acids, and acidulous fruits should be given from time to time ; and the circulation may be equalized by cooling diaph- oretics, as ipecacuanha, hyoscyamus, and nitre, with small doses of camphor. Ipecacuanha, in free or frequent doses, is one of the best reme- dies that can be prescribed; and when bilious colluvies require to be removed, it may be given so as to procure full vomiting, as advised by Stoll, Finke, and others. Constipation ought always to be prevented; but heating and irri- tating cathartics ought to be withheld. The tartrate of potash, or of potash and soda ; tam- arinds, or the supertartrate of potash with the confection of senna, the inspissated juice of the sambucus, &c, or any of the aperient electu- aries in the Appendix (F. 82, 96, 98), and mild laxative enemata, are the most appropriate. Derivatives, as warm manuluvia, are occasion- ally of use, and are advised by Hoffmann and Lordat. Duges and some French practition- ers direct the application of cupping glasses on the mammae. When blood-letting has been employed, or is not indicated, dry cupping over the loins or sacrum may be resorted to. Opi- um and other narcotics are most beneficial in the form of Dover's powder. It is only in the more urgent cases that cold, either externally or in lavements, and other means about to be recommended, need be prescribed. 247. b. If the haemorrhage has passed into a chronic or into a passive state, the foregoing treatment is no longer appropriate. Tonics and astringents are then required, especially the preparations of catechu, or those conjoined with opium, as directed by Wendelstatt; the tincture of the sesquichloride of iron ; the tere- binthinates and balsams; the acetate of lead and opium ; the sulphate of alumina or the me- tallic sulphates; and the other astringents al- ready recommended for other asthenic or pro- fuse haemorrhages (v 40-45). It is in the pas- sive form of the disease that the secale cornutum seems to be most serviceable. It may be given in decoction or powder. De Wedekind and Sauter advise the exhibition of the Juniperus Sabina, in doses of from ten to twenty grains of the powder, thrice daily, but it should be exhibited with caution, and its effects atten- tively watched. [Dr. C. D. Meigs recommends in these cases a decoction of the roots of the common black currant and the dew-berry: a handful of each to be boiled in two quarts of water, and after straining the liquor, to give a wine-glassful every hour or two.] 248. c. In delicate or nervous females, in whom 134 HEMORRHAGE FROM THE UTERUS—Treatment. metro-haemorrhage soon assumes a passive character, and gives rise to various nervous affections, an early recourse to restoratives, astringents, and sedatives is often necessary. Camphor, with nitrate of potash and opium, or hyoscyamus, in conserve of roses ; Dover's powder with catechu; the infusion of roses with sulphuric acid and anodynes ; the balsam of Peru or of Tolu, in the form of pills, with magnesia or powdered rhubarb, or with oxyde of zinc, and small doses of opium, according to the peculiarities of the case, may be severally employed. 249. d. If the haemorrhage continue, or be- come excessive, or occasion exhaustion, or any alarming symptom% the use of cold externally and internally has been very generally recom- mended. Hoffmann and Leake advise cold fluids to be taken in large quantity; Pezold, very cold clysters, and the external application of pounded ice to the hypogastrium ; numerous writers, various cold epithems. on the loins, tops of the thighs, vulva, &c.; and many recent authors, the cold affusion on these situations. But these require much discrimination. They are not always appropriate in the passive states of the disease, and they are serviceable chiefly when the active form has become excessive or dangerous. Yet I have seen recourse to them fail in some instances, and productive of injury in others. If resorted to prematurely, they may be followed by inflammatory action in the uterus, peritoneum, &e, or by severe rheumatic attacks. I have, therefore, had recourse, in extreme or prolonged cases, to the spirits of turpentine, either in a draught, or in an enema, or in the form of epithem or fomentation applied over the hypogastrium, and always with suc- cess. This practice was first adopted by me in 1819, in metro-haemorrhagia occurring after delivery, and has been pursued by me in other haemorrhages, whenever it was considered ad- visable speedily to arrest them. In 1820, I publicly recommended this treatment; and I know that it has succeeded with those who were thus led to employ it. [Dr. Chapman relates cases in his practice where emetics have not only promptly arrested haemorrhage from the uterus, but relieved that condition of the system which predisposes to it. These were chronic cases of an inactive kind, which had resisted the ordinary modes of treatment.] 250. e. When the haemorrhage is symptomatic of organic disease of the uterus, it is generally prolonged, or returns frequently, and is inju- rious more from this circumstance than from its violence at any particular time. It is also often remittent or periodic, the intervals vary- ing in different cases; but the discharge gen- erally subsides spontaneously after local pleth- ora or determination is removed, and returns again as soon as the organic change has estab- lished vascular fluxion, or congestion in the uterine organs. Although merely a symptom of the existing organic lesion, yet its frequent recurrence, and the consequent anaemia, sink- ing, and serious nervous symptoms require that it should receive the chief attention in the treatment; and that tonics, astringents, resto- ratives, and anodynes should be liberally, but appropriately exhibited. When the haemor- rhage is symptomatic of ulceration, or of ma- lignant disease, injections, per vaginam, with the solutions of the chlorides, particularly of the chloride of lime, or with pyroligneous vin- egar, or with the solutions of creasote, should be resorted to in addition to the means just mentioned. When it is occasioned by a poly- pus, or by a tumour on which a ligature may be placed, then this ought to be applied. 251. The third intention, viz., to prevent the return of metro-hamorrhagia, need hardly be en- forced in the accidental form of the disease; but it is of the first importance in the constitu- tional, habitual, or periodic states. In order to fulfil It, the remote causes ought to be re- moved or avoided, and the patient be placed upon a strict diet or regimen. Every source of local and of general and mental irritation should be shunned. The horizontal posture ought to be retained as long as possible for some time previously to and during the dis- charge ; and, in the intervals only, gentle ex- ercise should be taken in the open air. The food ought to consist chiefly of mucilaginous and farinaceous articles of easy digestion ; and asses' milk, with Seltzer water, as advised by Hoffmann, may be used both as a beverage and as an article of diet. The patient should be kept cool; she ought to sleep on a mattress, rise early, or remove to a couch ; and, if she be married, lie apart from her husband. If the haemorrhage be active, and dependant chiefly upon general or local plethora, a small blood- letting from the arm may be resorted to just before the expected accession of the haemor- rhage ; or small and frequent doses of ipecac- uanha, so as to occasion either nausea or vom- iting, may be tried, as directed by Hoffmann, Ranoe, Holst, Dalberg, and others. In cases depending chiefly upon debility, the prepara- tions of cinchona, of iron, or of other tonics ; the cold plunge or shower bath and salt-water bath; the mineral waters of Tunbridge or of Bath; the factitious waters of Pyrmont, Spa, or of Seltzer, and a light diet, will be of great service. When the recurrence of the discharge is owing to organic lesion, cold bathing is in- appropriate, and the mineral waters just men- tioned require to be tried with circumspection. Those of Ems, of Carlsbad, or of Marienbad, however, will often be employed with benefit. 252. C. Treatment of puerperal metro-hamor- rhagia.—a. Previously to the sixth month, uterine haemorrhage should be treated altogether as described in the article Abortion. If the foe- tus and membranes have entirely come away, and the discharge continue from a passive state of the uterus, the exhibition of spirits of turpen- tine in an enema will rarely fail of arresting it; but the practitioner should ascertain that no part of the placenta or membranes remain in the uterus or vagina, causing irritation and prolonging the discharge. When the uterus is thus inactive after abortions, the secale comu- tum or biborate of soda, or the spirits of turpen- tine, may likewise be exhibited to procure its contraction. 253. Desormkaux considers that haemor- rhage may take place in the early months of pregnancy, so as partially to detach the placen- ta, but that the clot that is formed between it and the uterus will often arrest the haemor- rhage, and adhesion of the detached portion subsequently occur; and he refers to a case HEMORRHAGE FROM THE UTERUS—Treatment. 135 by Noorthwyk in support of his opinion. On this ground, he advises having recourse, at the earlier periods of gestation, to plugging the va- gina, as recommended by Leroux, after bleed- ing and the usual means of arresting the haem- orrhage have failed. (See Abortion, 6 26, et seq.) At these periods, the uterus is still more or less unyielding, and the resistance to farther effusion is considerable. But in slight attacks, or at the commencement, the obstacle afforded by the plug may hasten the complete detach- ment of the ovum, by favouring the accumula- tion of blood between it. and the uterus ; and either a copious internal haemorrhage may thereby be produced, or the ovum, being de- tached, may be prevented by it from being thrown off, and be retained for a long period, keeping up irritation and haemorrhage, or a continued draining, with occasional exacerba- tions or a putrid discharge. Indeed, this oc- currence is not rare in the early months, inde- pendently of the plug, although the use of it before the expulsion of the ovum, and when the os uteri is soft or yielding, is more likely to occasion than to prevent it. When, how- ever, the os uteri is firm, and the discharge copious, it is often of service ; but it is chiefly after the ovum is expelled, in cases of flooding before the fifth month, that plugging is most efficacious if efficiently employed. Care should be taken that the plug do not press injuriously upon the urethra. Mr. Ingleby directs that it should remain undisturbed for twenty-four hours or longer ; but the supervention of inter- nal haemorrhage should be kept in view, and the case carefully watched. 254. When the blood escapes in small quan- tity only, and there are no pains present, and no disposition in the os uteri to dilate, the con- stitutional powers being unimpaired, an attempt should be made to prevent a return of the dis- charge, by the means already described both in this article and in that on Abortion. But, as Dr. R. Lf.e justly remarks, where the flooding is profuse at first, or is renewed with violence, in spite of efforts to check it, the continuance of pregnancy to the full period cannot be ex- pected, and it will be of no avail to take blood from the arm, and to administer internal rem- edies with any other view than with that of arresting the discharge, and thereby averting danger. In these circumstances the speedy evacuation of the uterus is the chief indication, as the slightest cause may reproduce the haem- orrhage in an alarming manner, while the par- tially-detached ovum remains. But, in the early months of pregnancy, this intention is not so easily accomplished as at later periods. Puncturing the membranes, in order to excite the uterus, is advised by Rigbv, R. Lee, and Merriman •. but before the fifth or sixth month this may not be easily performed; and, until the sixth or seventh, the hand, however small it may be, will not readily be admitted into the uterus. The ergot of rye has been recommend- ed by Neale, Negri, Ryan, and numerous American as well as European practitioners, in order to procure the contraction of the womb in such cases. It may be given in pow- der, or in decoction, with three or four drops of the oleum Pulegii, as advised by Dr. Ryan.* * [Dr. Chapman observes that " ergot is shown, by the well-conducted experiments of Dr. Charles Byrd, to have I have prescribed it successfully both alone and with from ten to twenty grains of the bi- borate of soda. An enema, containing an ounce or an ounce and a half of spirit of turpentine may be thrown up, if these fail. A judicious recourse to these means will generally super- sede the use of the plug or puncturing the membranes, the propriety of which latter, be- fore the sixth month, is denied by Mr. Ingleby and some others. Wherever, in such cases, the end can be obtained by the use of medicine, recourse to any operation, however trifling, should be avoided. Instances, however, may occur about the fifth or sixth month in which perforating the membranes is required, in ad- dition to the other means just advised. The cold affusion, or the dashing of a wet napkin against the external parts, or the application of the turpentine epithem on the hypogastrium, may be also resorted to when the case becomes urgent. 255. b. When in the third or fourth month the haemorrhage is continued, draining, or re- mittent, a merely partial evacuation of the ute- rus should be suspected, especially if the dis- charge become offensive ; or if the fcetus, with the whole of the appendages, have been ascer- tained to have come away, a flaccid or relaxed state of the uterus may be inferred. In such cases, a careful examination will discover one or other of these states, which will generally be removed by the medical means just advised, and especially by the exhibition of the spirit of turpentine by the mouth, or in enemata. The recommendation of Drs. Haighton and Blun- dell to inject the uterus with astringent fluids, if at all advisable, is most likely to be service- able in cases where a portion of the ovum has been retained in the uterus, and is passing into decomposition. [The blood-vessels of the uterus do not at- tain a sufficient size until the seventh month of pregnancy to pour out blood in so great a quantity as suddenly to destroy life, though the discharge may be very profuse, and produce alarming symptoms. The remedies on which we rely to check haemorrhage in the early months are, venaesection, where the patient is plethoric and the circulation excited; rest in the horizontal position ; cool air; ice in a bladder, or cold vinegar and water over the hy- pogastrium ; cold, acidulated drinks; pills of the acetate of lead and opium ; the introduction of a sponge into the upper part of the vagina ; and where these all fail, puncturing the ovum,. and bringing on uterine contraction by the use of the ergot. Where the bleeding is kept up by the presence of the ovum in the uterus, and it cannot be reached by the finger, a curved wire, or a polypus or lithotomy forceps may be intro- duced, provided the os be sufficiently dilated, and thus the ovum may be extracted.] 256. c. Hamorrhage after the sixth month, al- though occurring most frequently from attach- ment of the placenta upon the cervix uteri, may also take place when this does not exist. In no remedial effect except on the gravid uterus. Given un- der other circumstances, it appeared to be utterly inert, even in relation to the system of the female, the womb in- cluded. Were it, too. endowed with the power ascribed to- il, should it not be displayed in regard to haemorrhages gen- erally? But in epistaxis, haemoptysis, and haematemesis. it has none, I am persuaded from all my observations."__ (Lectures on Hamorrhages," &c, Phil., 1845.}] 136 HEMORRHAGE FROM THE UTERUS—Treatment. this stage of pregnancy, as well as at earlier periods, if the discharge be in small quantity or moderate ; if it have not proceeded with much rapidity; if it stop soon ; if no large clots be formed in the vagina; if the cervix have its usual feel, showing that the placenta is not at- tached there, and that no large coagula are re- tained in the os uteri; if the child be still alive ; if there be no indication of the accession of la- bour ; and if the discharge become pale and watery, we may conclude, with Dr. Burns, that the full period of gestation may be reached. In this case the treatment already directed in ac- tive haemorrhage ought to be adopted. But where the effusion is profuse, or continues, and the strength of the patient is impaired by it, the fcetal membranes should be punctured, the liquor amnii evacuated, and the uterus roused to action by the means just advised (r 254), aided by frictions over the hypogastrium, and by dilatation of the os and cervix uteri. 257. d. When the placenta is attached over the cervix uteri, as evinced, on a careful examina- tion, by its fibrous vascular structure, by its ad- hering to one part of the uterus and being sep- arated at another; by the renewal of the haem- orrhage during labour pains ; and by its occur- rence without any obvious exciting cause, the utmost decision and dexterity on the part of the practitioner are required. If flooding occur to an alarming extent in the seventh or eighth month, an examination should be instantly made, and while the blood is actually flowing. In some cases, where a small portion of the placenta lies over the os uteri, coagula may close the orifices of the bleeding vessels, and the patient may go on to the full time.* In these, the haemorrhage is seldom very pro- fuse ; and this result cannot be expected. The general recurrence and increased violence of the effusion, until the patient either expires, or is delivered by art, demand that a rule of prac- tice should be laid down ; and the rule first de- vised by Levret, and now generally received, is the speedy performance of artificial delivery. Dr. R. Lee states that he has seen only one case of flooding from the position of the pla- centa, followed by recovery, without artificial delivery; and, in order to accomplish this, he recommends the hand to be passed into the va- gina, as in turning, without waiting for the pains of labour, or the dilatation of the os uteri, and carried steadily forward through the os, in a conical form, between the uterus and placen- ta, at the part where their separation has taken place. The membranes are then to be rup- tured, and an inferior extremity of the child brought down, and the infant and placenta * [The fact was first established by Dr. Jones, that when •an artery is divided, nature employs certain means adapted to arrest.the flow of blood ; the artery contracts and retracts, and a coagulum is formed within its orifice. The same means are employed by nature to prevent fatal hemorrhage 'from the uterus when the placenta is detached ; and if this were not the case, death from hsemorrhage would probably take place in all cases immediately after the expulsion of the child and separation of the placenta. The same mus- cular contractions which expel the contents of the gravid AUerus close the mouths of the exposed vessels in the lining membrane until coagula of the fibrin of the blood are form- .ed within them, which effectually prevents the farther ef- fusion of blood ; a result which is facilitated by the oblique valvular manner in which the veins open into the cavity of the uterus. All the different means which prove efficient in checking the discharge in uterine hemorrhage either excite the contractions of the uterus or promote the coag- ulation of the blood within the vessels.] slowly extracted. The hand, however, should not be forcibly introduced while the os uteri is rigid and undilatable. Until it becomes soft, the flow of blood should be checked by the re- cumbent posture, by cold applications, and the plug. But this latter ought not to be inserted when the os uteri is soft and dilatable. In the rigid state of this part, in haemorrhage from this cause, it will command the effusion, until the operation of turning can be safely perform- ed ; but, as soon as this may be attempted, it becomes inadmissible. [According to the statistics of the Maternite at Paris, from 1797 to 1811, out of 20,357 wom- en delivered, there were eight cases of pla- cental presentation, or 1 in 2554. During six years and nine months, in the Dublin Lying-in Hospital, during Dr. Clarke's attendance there, four cases of placental presentation, or 1 in 2596; and Dr. Collins met, in the same institution, with 11 cases of placental presentation in 16,654 labours, being in the proportion of 1 to 1492. Out of 174 cases of placental presenta- tion recorded by different authors, Dr. Church- ill states that 48 proved fatal, or nearly 1 in 3; and about the same proportion where the placenta was attached at the fundus. Dr. Robert Lee states that he had seen 38 cases of uterine haemorrhage in the latter months of pregnancy from partial or complete attachment of the placenta to the neck of the uterus, of which 14 proved fatal.] 258. e. If flooding occur during the first stage of labour, at the full time, the membranes should be immediately ruptured, as recommended by Clement, Puzos, Kok, Rigby, Baudelocque, Denman, Merhiman, D. Davis, Blundell, Lee, Ramsbotham, Sweatman, and others; but if the discharge should still continue, and the pains become more and more feeble, and the patient exhausted, delivery must be accom- plished by turning, by the forceps, or even by embryotomy, according to the circumstances of the case. In less imminent cases, the ergot of rye and other means already mentioned (§ 254) may be tried before recourse be had to these operations. Mr. Ingleby, however, con- siders that many of this description of cases are occasioned by the injudicious use of the ergot; hut, when it is employed for the arrest of the discharge, and for the purpose of procu- ring uterine action, this objection does not ap- ply either to it, or to other means intended to exert a similar operation. After the liquor am- nii has escaped, the os uteri still remaining rigid, there are objections to the exhibition of the ergot; and in such a case, plugging the vagina, as advised by Burns, Dewees, Capu- ron, Gardien, Davis, &c, may be resorted to, with the aid of friction and moderate pressure on the abdomen, in order to increase uterine action. The possible occurrence, however, of internal haemorrhage should not be overlooked ; and if this take place, the still more active in- terference just mentioned must not be delayed. But the plug should not supersede rupturing the membranes when flooding occurs at the commencement of labour at the full term. 259. /. Hamorrhage after the birth of the foetus, and before the expulsion of the placenta, is frequent, and often sudden and profuse. In this case, strong pressure should be made over the hypogastrium, in order to excite uterine ac- HEMORRHAGE FROM THE UTERUS—Treatment. 137 tion. A binder ought to he firmly applied over the abdomen, several folded napkins being placed under it, so that the fundus uteri be compressed. Dr. R. Lee advises the hand af- terward to be introduced to remove the placen- ta, but the removal of it should not be attempt- ed until contraction of the uterus commences. After contraction, and the expulsion or with- drawal of the placenta, he directs a cloth, wet with cold vinegar and water, to be applied to the external parts, cold acidulated drinks to be given from time to time, and the patient to be preserved for two or three hours in a state of perfect repose. This plan will generally suc- ceed when the haemorrhage and retention of the placenta are caused by inactivity of the uterus. But when irregular action of the or- gan, or spasmodic contraction of the os inter- num or externum uteri, retains the placenta either altogether or partially, and thus causes internal haemorrhage, additional means, espe- cially the exhibition of opium by the mouth, are required. The passage of the hand, in order to remove the placenta, then demands caution and perseverance. If it cannot be accomplish- ed, the turpentine enema or embrocation will generally aid in removing the difficulty. If the flooding arise from morbid adhesion of a portion of the placenta, the adhesion must be separated by the hand in a manner that will readily suggest itself. Dr. T. Ramsbotham at- tributes these adhesions to partial separation of the placenta during pregnancy, from some accidental cause, followed by a slight discharge, the extravasated blood exciting inflammation of the separated surfaces with effusion of lymph, and the consequent agglutination of them. This opinion is probably correct. 260. g. Flooding after the expulsion of the pla- centa requires a modified practice, according as it arises, 1st. From atony of the uterus; fid. From imperfect or remitting contractions ; 2d. From a portion of the placenta left in the uterus; and, 4th. From inversion of the organ. As in haemorrhage previously to the complete expulsion of the placenta, so in this the blood may be retained in the cavity of the viscus, by coagula, or by a portion of the secundines lodged in the os uteri or vagina. In every case, therefore, the state of the uterus and the integrity of the placenta should be ascertained. Where simple atony of the uterus is the chief cause, constant and well-directed pressure on the fundus uteri, especially by the hand ; the sudden application of cold, or effusion of cold water; the turpentine enema, or draught; the ergot, &c., are the most efficacious means. If the haemorrhage be internal from any of the causes just stated, the same measures will gen- erally procure their removal, by contracting the uterus ; but if these fail, they should be removed by the hand. The draining or recur- ring haemorrhage, the expulsion of clots, the offensive nature of the discharge, and the con- stitutional effects consequent upon the presence of a portion of the placenta in the uterus, de- mand at first the same means as other states of the disease ; but afterward, and particularly when serious constitutional symptoms super- vene, indicating a remarkable diminution, and marked vitiation of the vital current, additional or other remedies should be employed. Weak solutions of the chloride of lime, or of soda, 18 should then be injected per vaginam, or even into the uterus ; and the decoction of cincho- na with the chlorate of potash, or with hydro- chloric acid ; camphor in frequent doses ; an occasional enema with spirits of turpentine, or draught with the same and castor oil; the biborate of soda, and other means calculated to support the vital energies, to increase the ex- creting functions, and to enable the uterus to retract and discharge the matters retained in it, should be prescribed. [Dr. Thomas Radford, of England, has em- ployed galvanism with great success in the treatment of cases of uterine haemorrhage, ac- cidental or unavoidable, accompanied by ex- haustion, and occurring before, during, or after labour. " I am satisfied," he says, " from pos- itive trial of the remedy, that it will be found a most important agent in tedious labour, de- pending upon want of power in the uterus, and where no mechanical obstacle exists. I would also suggest the probability of its proving val- uable in originating uterine action de novo, in cases where it may be considered necessary to induce premature labour. It seems to me, al- so, to be worthy of trial in certain cases of menorrhagia in the ungravid state, where, on vaginal examination, the uterus is found to be atonic, as evidenced by its large, flaccid con- dition, and the patulous state of the os uteri." His mode of applying galvanism is the fol- lowing : The brass ball of the vaginal conduct- or is to be passed up to the os uteri and moved about, at intervals, on to various parts of this organ ; at the same time, the other conductor must be applied to the abdominal parietes over the fundus uteri. Shocks may be also passed transversely through the uterus, by simultane- ously applying the conductor on each side of the belly. The application should be used at inter- vals, so as to approximate, in its effects, as nearly as possible to the natural pains. It may be continued until it meets the exigences of the case. Dr. Radford has also been led by his expe- rience to conclude that on a complete separa- tion of the placenta the haemorrhage is imme- diately and completely suppressed, provided the uterus is in a condition to so far contract as to force down the head with the placenta upon the uterine openings. By this practice it may be said that the life of the child is sacri- ficed ; but this will not always happen. We find from hospital and individual reports, that the child is usually dead, when the case has been treated by the present recognised means. " In nearly all the cases which I have col- lected and referred to in my paper," he remarks, " of expulsion of the placenta by the natural ef- forts, we find that the mother recovered ; and when this fortunate event did not happen, it depended upon the serious impression made upon the vital powers before the placenta was completely detached. " It may also be stated that uterine phlebitis takes place more frequently in cases of placen- ta praevia, when the ordinary practice is adopt- ed, than we observe in the same number of cases of accidental haemorrhage. This result in the opinion of the writer, arises from the contusions and slight lacerations which are consequent upon a forced delivery." 138 HEMORRHAGE FROM THE UTERUS—Treatment. Dr. Radford has, from these circumstan- ces, been led to recommend the following prac- tice : " 1st. Then, as neither delivery, nor detach- ing the placenta, ought ever to be attempted until the cervix and os uteri will safely allow the introduction of the hand ; rest, the applica- tion of cold, but, above all, the use of the plug must never be omitted in cases where they are respectively required. " 2d. If there are unequivocal signs of the child's death, the placenta is to be completely detached, and the membranes are to be rup- tured. The case is then to be left to the natu- ral efforts, provided there be sufficient uterine energy; if otherwise, the ordinary means are to be used, and, in addition, galvanism. " 3d. When a narrow pelvis exists in con- nexion with placenta praevia, the practice is to detach the placenta and to remove it, then to perforate the head as soon as the condition of the parts allow, and to extract it by means of the crotchet. " 4th. When the os uteri is partly dilated, and dilatable so as to allow the easy introduc- tion of the hand, when the membranes are ruptured and strong uterine contraction exists, the practice is to detach the placenta com- pletely. " 5th. In all cases of exhaustion, as already referred to in my paper, the practice is to draw off the liquor amnii by perforating the placenta, as then recommended, then to detach com- pletely this organ, and apply galvanism. " 6th. In all cases of partial presentation of the placenta, the artificial rupture of the mem- branes will generally be found sufficient to ar- rest the haemorrhage ; but if that should prove ineffectual, then we must apply galvanism. " The practice of detaching and removing the placenta was adopted by some of the older writers; and as I have mentioned in my paper 4 On Galvanism applied to the Treatment of Uterine Haemorrhage,' I detached this organ in the year 1819, although it was not my custom to do so."—Prov. Med. and Surg. Journ., 1844. Dr. Simpson, of Edinburgh, has proposed, in these cases of haemorrhage from placental presentation, that the placenta should be first extracted, leaving the foetus to be expelled by the natural efforts of the uterus or otherwise. Dr. S., as well as Dr. Radford and Dr. Kinder Wood, relate instances where this procedure has proved successful; in one case the placen- ta was extracted two hours before the birth of the child. This method is particularly recom- mended in those cases in which turning or rup- ture of the membranes is inexpedient or im- practicable ; as in cases where haemorrhage occurs to an alarming extent while the os uteri is still small and rigid ; in unavoidable haemor- rhage in first labours ; in placental presenta- tions where the patient's strength is already so sunk, from the flooding, as not to allow, with- out danger, of immediate turning or forcing de- livery ; in cases where the child is known to be dead, &c.—(Lond. and Ed. Month. Jour. Med., Feb., 1845.)] 261. The occurrence of haemorrhage after delivery, while the uterus appears to be con- tracted, upon which Dr. Gooch has so unneces- sarily insisted, is nothing more than its con- nexion with an imperfect, remitting, or irreg- ular contraction in some cases, and with de- termination of blood in others ; states pre- viously known to the profession, and requiring, at most, but a modification only of the means insisted upon in the course of this article. In these, as well as in other cases, the applica- tion of pounded ice has been much praised ; but the continued application of great cold is less beneficial than the shock produced by the affusion of moderately cold water, or by dash- ing a wet napkin upon the hypogastrium and external parts. Indeed, the former may cause an imperfect or irregular contraction to pass into a state of relaxation, and thereby perpet- uate the haemorrhage. With respect to the hour-glass contraction of the uterus, insisted upon by Dr. Burns and others, in connexion with flooding, the perspicacious remarks of Dr. Malins should be borne in mind. This acute physician observes that, as the contraction of the uterus in the uniinpregnated state, dividing it into two portions, disappears under gesta- tion, the whole uterus then forming but one spheroidal cavity, so the removal of the dis- tending causes allows the organ to recover, in a great degree, its original shape during con- traction, and that thus two cavities again ex- ist, in some measure divided by that contrac- tion usually denominated the os internum ute- ri, perfectly natural, indeed, in character, but to which the name of hour-glass contraction, as denoting a preternatural state, has been in error so constantly applied. The contraction of the circular fibres, which thus takes place, dividing the upper part of the genital canal into two chambers, when excessive, the other por- tions of the organs being relaxed, is not infre- quently associated with haemorrhage, either while the placenta is still retained in the upper chamber or after it has been thrown off, coag- ula filling the lower cavity formed by the cer- vix uteri. The introduction of the hand into the uterus in order to excite it to action, or to press upon the part to which the placenta was attached, as advised by Dr. Gooch and others, can seldom, under judicious management, be necessary; and it is very doubtful if it will ever prove serviceable. Plugging the vagina, after delivery at the full time, requires the ut- most caution and constant watching, even when the uterus is firmly contracting, as it may fa- vour dangerous internal effusion. 262. D. The management of a patient after dangerous uterine hamorrhage constitutes an im- portant part of the treatment. Although the uterus is firmly contracted, and the patient seems comfortable, yet she ought not to be considered as altogether safe, as the uterus may again relax and the haemorrhage return. This contingency ought to be guarded against by applying a proper binder, by perfect repose, and by a full dose of opium, if irritability or restlessness exist. Her position ought not to be changed for several hours, and the horizon- tal posture must not be departed from on any occasion. The room should be darkened and well ventilated, and nutrient but ligft fluids, in moderate quantity, should be given at stated intervals. 263. iv. The particular remedial Measures advised by Authors for Uterine Hemorrha- ges require but little notice after the full ex- position of the treatment given above.—a. Vas- HEMORRHAGE FROM THE UTERUS—Treatment. 139 cular depletions, either general or local are di- rected by several writers, and particularly by Schenck, Lefevre, and Pelargus ; but they are admissible only in the more active states, and as means of prevention, especially in these. When practised so as to derive from the seat of haemorrhage, some advantage may accrue from local depletions, more especially from cup- ping over the sacrum or under the mammae, as advised by Hippocrates and Actuarius. Sev- eral of the ancients resorted to cupping on the breasts; Galen directed this operation to be performed over the hypochondria; and Gon- dret prescribed dry cupping, with large glasses, between the shoulders. Emetics have been prescribed, in order to derive the circulation from the uterus, after blood-letting has been resorted to, by Stoll, Gendron, Reidlin, and Kortom. Conradi employed them to procure contraction of the uterus, and the expulsion of coagula in uterine haemorrhage after delivery. They are certainly serviceable in some cases, but they require discrimination, and their ef- fects ought to be carefully observed. 264. b. Internal refrigerants, particularly nitre and cold drinks, have been praised by several of the older writers. MM. Martinet and Des- landes have recently given the nitrate of potash in remarkably large doses — as much as six drachms in the twenty-four hours. It is not appropriate in cases of puerperal haemorrhage, although it is sometimes of service in the ac- tive forms of the disease unconnected with pregnancy. I have given it in haemorrhage af- ter abortion, but with little or no benefit. The hydrochlorate of ammonia is more likely to be serviceable, especially in cases of debility, and when the discharge is draining or remittent. It may then be given with cinchona, or small doses of opium. 265. c. Of the application of cold little farther need be stated. It has been generally prescri- bed by writers from Hippocrates to the pres- ent time. Collomb, Doemling, Gauthier, Hi- ensius, Chaussier, and most modern authors, recommend it, both internally and externally, in the forms of epithem and injection. Ranoe, Loeffler, Josephi, D. D. Davis, and Olivier direct cold drinks; while Fieliz and Thomann consider cold in any form inappropriate in ute- rine haemorrhage after delivery, and in the pass- ive states of the disease. There is much jus- tice in this. The recourse to cold requires great discrimination ; for, if too long applied, or if the cold be too great, much mischief may be produced by it. The sudden and tempora- ry application of cold, so as to produce more or less shock to the frame, is certainly more beneficial, and more generally appropriate than a prolonged recourse to it. 266. d. Astringents have been very generally administered, both by the mouth and per vagi- nam, in metro-haemorrhagia. Aluminated whey has been prescribed by Lentin, Pasta, Mul- ler, Lindt, Stroem, and Hufeland. Thileni- us has directed it to be employed topically, by means of a sponge. Wendt and Aaskow have recommended the sulphuric acid with lauda- num ; Gebel, the tincture of the sesquichloride of iron; and Fothergill, Carron, and Wen- delstatt, the preparations of kino or of catechu. These, medicines are even now in general use, but are most beneficial in the more passive states of the disease, unconnected with preg- nancy or childbirth, and when the discbarge is moderate and prolonged. Of the numerous as- tringents mentioned by writers, the acetate of lead, in doses of two grains to six or seven, re- peated according to the urgency of the case, has been most praised by modern authors, and especially by Reynolds, Heberden, Mitch- ell, Young, Williamson, Amelung, Thomson, &c. When the flooding is profuse, or occurs in connexion with childbirth or abortion, only the most energetic astringents and the most rapid in their effects ought then to be given internally ; and of these, the spirits of turpen- tine; the ergot of rye (Spajrani, Cabjni, &c, in Ann. Univers. di Med., 1830); and the acetate of lead, in large doses, with opium in acetic or py- roligneous acid, are most deserving of notice. 267. e. The more energetic tonics, in large do- ses, have likewise been directed. They are appropriate in cases of debility, when the dis- charge is prolonged without being excessive; and when it is unconnected with pregnancy or active determination to the uterus. In these circumstances, and when the disease is period- ic, the preparations of cinchona have been pre- scribed by Stroem, Starke, Duncan, Bang, Picque, &c. ; the tincture of cinnamn by Plenck, Vogel, and Schneider ; and the sul- phate of iron, and other chalybeates, by Rath, Thilenius, and Doemling. The sulphate of quinine, with sulphuric acid and tincture of cin- namon, or with sulphate of iron in the form of pill, will be given with advantage in many ca- ses of this description. 268. /. Ipecacuanha in small doses has been much used by Paulisky, De Meza, Bruck, Holst, Loeffler, Stoll, Dalberg, Denman, and others ; and small quantities of tartar emet- ic have been recommended by Chalmers. The former of these may be useful when the uterus contracts irregularly, and when the placenta is retained from this cause. But it is chiefly in combination with opium, or in frequently re- peated doses, that any advantage can be ex- pected from it. In haemorrhage after delivery but little benefit will be derived from opium, es- pecially if given in large quantity, or depended upon chiefly. When thus exhibited, it will rather impair than promote the contractions of the uterus. Yet circumstances will some- times arise to justify the praises of opium ex- pressed by Horstius, Heister, Young, Smel- lie, Ranoe, Chesneau, and Garthshore, es- pecially in uterine haemorrhage unconnected with pregnancy, or in that occurring in the ear- lier months of gestation. In these cases it may be given with dilute sulphuric acid (Aaskow) ; or in clysters, as directed by Mr. Copland. Harcke advised it to be used in injections thrown into the vagina—a method by no means to be advocated ; and every practitioner of ex- perience will be aware of the danger of admin- istering opium, unless in very small quantity, in the form of enema. ["The more I prescribe opium," says Dr. Chapman, " the stronger is my conviction that it exercises a very general power over haemor- rhage, provided adequate depletion has been practised, and which I think it does by its oper- ation on the nervous system. Commonly it, or some of its preparations, is given alone, but the Dover's powder often answers better; and 140 HEMORRHAGE FROM THE UTERUS—Treatment. in some instances a union of opium, ipecacuan- ha, and camphor is still more to be preferred." Our experience coincides with that of Dr. C. in relation to the use of this article. A full dose of Dover's powder, after proper and suit- able venaesection, will generally check haemor- rhage, whether it be from the uterus or any other organ.] 269. g. In passive metro-hamorrhagia, partic- ularly when the powers of life are depressed or exhausted, brandy or other spirits have been resorted to by many practitioners, often in large quantity. Stimulants of this description are apt to give rise to a very serious affection of the head, and to protract convalescence. Am- monia, or camphor (Ettmuller), is less objec- tionable in such circumstances ; and a judi- cious recourse to spirits of turpentine, as advi- sed above, is much more efficacious and less hazardous. Of other internal medicines rec- ommended by writers, no farther notice than the simple enumeration of them need be taken. The fungus militensis has been mentioned by Linn.-eus ; the bursa pastoris, by De Meza ; the geum urbanum, by Stroem ; the decoction of the fruit of the hippocastanus, by Hufeland ; tannin, by Cavalier ; savine, by Rave, Fiest, and Wedekind ; purgatives, by Lentin, Strack, and Conradi ; and the pimpinella, by Riedlin. Whatever effects these may produce in the haemorrhage occurring independently of preg- nancy, but little benefit can be expected from them in those supervening during the puerpe- ral states. [We believe that a current of galvanism, passed directly through the uterus, as directed above by Mr. Radford, will speedily induce ute- rine contractions, and thus check haemorrhage from this organ. Farther trials with it are, however, needed, before its efficacy can be con- sidered as fully established. Monesia has been recommended by various writers, in different forms of haemorrhage from the uterus; and Prof. Simpson, of Edinburgh, recommends gallic acid, in doses of from ten to twenty grains in the twenty-four hours, made into pills. He states that it possesses the ad- vantage of not confining the bowels; and it forms the active ingredient in Ruspini's styp- tic. The infusion of matico has also been given with decided benefit, where an internal styptic was needed (Braithwaite's Retrospect, part vi., art. 79, and part viii., art. 7). Dr. Dewees is a strong advocate for the sugar of lead.] 270. h. Various external means of arresting flooding after delivery have been adopted, and frequently with success. Friction of the abdo- men, particularly when the uterus contracts ei- ther imperfectly or irregularly, and compression over the fundus of the organ by the hand, or by compresses, bandages, &c., have been very properly insisted upon by Lev ret, Tallony, Zeller, Vogel, Smellie, Osiander, Ingleby, Ramsbotham, R. Lee, and by most modern wri- ters. Loeffer directed that pressure should be made by means of a sand-bag. Dr. D. Da- vis and Dr. Beatty have recommended banda- ges constructed on purpose. Pressure on the descending aorta, through the abdominal pari- etes, has been favourably mentioned by La- tour and Ingleby. Ploucquet advised the pressure to be made by the hand introduced into the relaxed uterus ; and Eichelbergeb has adduced an instance of the success of this method. Injections of various kinds into the uterus have been employed. Prosper Alpinus, Thilenius, and Pasta prescribed the mineral acids much diluted ; Galen, the juice of the plantago; Astruc, diluted vinegar ; and Kok, astringent infusions, in this way. Fieliz di- rects the hand wet with vinegar; Wendel- statt, lint moistened with much-diluted sul- phuric acid ; and M. Gorat, a decorticated or divided lemon, to be passed into the uterus. 271. i. Plugs or tampons, moistened with va- rious astringent fluids, have been very general- ly resorted to since the praises bestowed on them by A. Parey, Hoffmann, Leroux, Thile- nius. Trioen, Held, Loeffler, Humberg, and Smellif. Some modern British authors have, however, supposed that the addition of astrin- gents is unnecessary, although they approve of the plug in nearly the same circumstances in which I have recommended it above (Y 253), namely, when the os uteri is rigid. Soft lint or sponge may be used ; but in such a manner as to fill completely the upper part of the vagina. 272. k. When all other means have failed— when the face is blanched; respiration is scarcely audible, or gasping or hurried; the pulse almost imperceptible or gone; the ex- tremities cold or clammy; the power of deglu- tition lost—transfusion should be resorted to, although the chances of success from it are few. Dr. Hamilton has, however, seen recov- ery take place from this state by the ordinary means ; but so fortunate an issue is rare. The question only is, whether the practitioner should still persist in the use of some of the more ap- propriate means, or have recourse to transfu- sion. The contingencies of resorting to it ought not to be kept out of view; for if air pass into the vein, immediate death will follow. Phlebitis may even supervene, although the operation has succeeded, and carry off the pa- tient. The propriety and success of this meas- ure have, however, been so far established by Dr. Blundell, Dr. Ingleby, and by some oth- ers, who have attempted it in circumstances of more doubtful propriety, as to justify the having recourse to it as an ultimum sed anceps remedium. 273. 1. The prevention of uterine hamorrhage, particularly in the puerperal states, is a subject of great importance. In the early months, the precautions recommended in the article on Abortion (y 26, et seq.) should be adopted. In order to prevent haemorrhage after delivery, Dr. Beatty and others advise an appropriate binder to be passed loosely round the abdomen, and drawn tight, as circumstances may require. I am convinced that a moderate degree of pres- sure on the parietes of the abdomen after de- livery is of service in preventing, not only ute- rine haemorrhage, but also some other diseases, especially the different forms of puerperal fe- vers, &c. [As haemorrhage from the lungs indicates, for the most part, something wrong in the con- dition of that organ, so haemorrhage from the uterus should lead us to suspect a morbid state of this viscus. We should particularly inquire whether there is a sense of pain or heat in the organ, extending to the lumbar region and low- er extremities, and whether the flow of blood may not alternate with other depraved and non- HEMORRHAGE FROM THE UTERUS—Bibliography and References. 141 sanguineous discharges of an offensive nature. If we cannot ascertain satisfactorily by the touch the precise pathological state of the ute- rus, we shall be warranted in having recourse to the speculum—an expedient which we never wish to see resorted to on ordinary occasions, and never, indeed, except as a last resource. In many of these cases, the suppression of the discharge is a subordinate consideration ; it may even prove a salutary evacuation, design- ed for the relief of a phlogosed condition of this important organ, as it often prevents the oc- currence of organic disease. Our chief object should be to arrest the progress, or relieve that condition from which the haemorrhage ema- nates. To this end, general and local bleeding ; the latter, by the occasional application of leech- es to the os itself; an alterative use of iron and conium, iodine, or mercury ; a mild diet; fre- quent sponging the body ; pure country air ; moderate but regular exercise ; and especially a cheerful and placid state of mind. When, in a later stage, we detect the presence of scir- rus and other serious organic derangements, we are obliged to resort to the use of narcot- ics and anodynes, especially the iodides, with conium, opium, sarsaparilla, &c. 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Paris, 2d edit., 1706.—P. T. Schacher, Diss, de Haemorrhag. Gravidarum, 4to. Lips., 1717. — Freind, Emmenologia, C. 12, 13.— Werner, Diss, de Affectibus cum llaemorrhagiis Uteri. 4to. Erford, 1715.—Mead, Medica Sacra, cap. 4.— Brunner, Diss, de Partu Pratteruaturali ob Situm Placenta; super Orific. Uteri internum, 4to. Argent., 1730.—F. Hoff- mann, Diss, de llacmorrhoico Mensium Fluxu in Virgine Observato. Hal., 1730. Consultat, cent, ii., iii.. n. 110; et De Eturi Hsemorrhagia Immoderata, obs. 7. Opp., ii., p. 230.—Chomel, Ergo Pr.i gnante superveniente Uteri Hiem- orrhag. Partus Manu Promovendus, 4to. Paris, 1743.— Riedlin, Lin. Med., p. 50, 1695. — Puzos, Memoires de l'Academie de Chirurgie, tome premier, 4to.—Gebauer, De Salubntate Hsemorrhagia Uteri, 4to. Erlang., 1746.—C. Linne, Hiemorrhagia Uteri sub Statu Gravid. Upsal, 1749. — Thurneysen, De Caus. Hiemorrhag. in Gravidis, 4to. Basil, 1750.—Erichson, De Haemorrhagiil Uteri sub Statu Gravid., 4to. Upsal, 1750.—D'Urbann, De Hiemorrhag. Uterina, 8vo. Edin., 1753.— Wessel, De Partu cum Haem- orrhagic ob Placentam Orificio Uteri Adhaerentem, 4to. Basil, 1753.— A. Pasta, Discorso Inierno al Flusso di San- gue dell' Utero dalle donne Gravide, 4to. Bergamo, 1752.— Staehlin, De Partu cum Hiemorrhagia Uteri conjuncto, 4to. Lugdun. Batav., 1753. — Reichard, De Hsmorrhag. Uteri Partum Insequente, 4to. Argent., 1755.—A. C. Lorry, QuKstio Medica. — An Partur. Accedente Hsmorrhagia Uterina, Partus, Diversa pro Diverso Casu Encbeiresi, promovend. * Svo. Paris, 1758.—Mauriceau, Des Maladies des Femmes Grosses, t. i., p. 386.— Lentin, Beytrage, iv., p. 28. —Young, On Opium, p. 76. — Thilenius, Medic, and Chirurg. Bemerkungen, p. 151.—Fothergill, Med. Observ. and Inquiries, vol. v., p. 160.—Trioen, Observ. Med. Chir., p. 18. — Heberden, Comment, in Morb. Historia et Curat., cap. 62.—Astruc, Traite des Maladies des Femmes, t. ii., p. 65, 110.—Stoll, Prelect., t. ii., p. 104, 381; Rat. Med., P. iii., p. 48 ; P. vii., p. 279.—P. Copland, Med. Facts and Observations, vol. iv., n. 9, p. 188. — Douglas, Med. Com- munications, 1., n. 6.—J. W. Gulbrand, De Sanguifluxu Uterino, and Edin. Medical Commentaries, vol. vi., p. 21.— E. Rigby, An Essay on the Uterine Haemorrhage, &c, 8vo. I Lond., 1775. — C. Roux, Observations sur les Pertes de Sang de Femmes en Couche, &c, Svo. Dijon, 1776 — Aaskow, De usu Opii in Hsemorrhagiis Gravidarum, 1777. —Eyeril, Sylloge, iv., p. 37.—Carron, Journ. Gen. de Med., t. xxxi., p. 241, 257, 353.— Wallis, Essay on the Conse- quences attending injudicious Bleeding in Pregnancy, Svo. Lond., 1781.-Denman, Essay on Uterine Hsmorrhagesde- pending on Pregnancy and Parturition, 8vo. Lond., 1766. —Fothergill, Memoirs of the Medical Society of London, vol. ii., n. 9.—Bang, Collect. Soc. Med. Hafn., i., no. 93 — Aaskow, Act. Reg. Soc. Med. Havn., vol. i., p. 49; Ibid., vol. ii., n. 4, p. 32; Ibid., vol. iii., p. 366; Ibid., vol. iv., p. 271, 284.—/. P. Frank, Dissertatio de Haemorrhag._Uteri ex Spasmo Secundinas Incarcerente, 4to. Ticini, 1789.— C. Strack, Observat. Medicinales de Una pra Ceteris Cau- sa propter quam Sanguis e Fseminarum Utero nimis proflu- it, 8vo. Berlin, 1794 (Accumulation of sordes in the diges- tive canal).— Millot, Observ. sur les Pertes des Femmes, Svo. An., vi.—Thomann, in Roeschlaub, Magazin der Heil- kunde, b. v., p. 257; et Annales Wurceb., ii., p. 215.— Siebold, Diss. Menorrhagia Uteri Haemorrhagia. Wurceb., 1799.— Clarke, Trans, of Soc. for Promoting Med. Knowl- edge, n. 13.—Boucher, Journ. Gen. de Med., t. xxiv., p. 380. —A. Leroy, Lecons sur les Pertes de Sang pendant la Grossesse, Svo. Paris, 1801. — Demangeon, De Fallaci atque Noc. Obturamenti in Haemonhag. Uteri Cohibend. Usu., 4to. Paris, 1803.—St. Amand, Diss, sur les Pertes de Sang, 6.— Thomson, In Med. Observ. and Inquiries, vol. iv. Lon- don, 1772.—Hooper, in Memoirs of Med. Soc. of Lond., vol. i., art. 18.—Alston, in Edin. Med. Essays and Observ., vol. v., p. ii.. p. 609— Otto, Selt. Beob., vol. i.,p. 95.—Hufeland and Harles, Journ. der Pract. Heilk., Jan., 1815, p. 85.— Fitzpatrick, in Lond. Med. Repos., vol. xvii., p. 295.—Au- thor, in Ibid., p. 298.—(See, also, Biblioo. AND Refer. to arts. Heart and Pericardium.) iii. Hemorrhage into the Pleural Cavities.— Acta Nat. Curios., vol. i.,tibserv. 142.—Marcellus Donatus, 1. iii., c. 9, p. 263.— Wepfer, De Apoplexia, p. 351. — Wei- kard, Vermischte Schriften, b. ii., p. 36.—Moigagni, Sed. et Cans. Morb., epist. ix., art. 4 ; epist. xvii., art. 17 ; epist. xxvi., arts. 3, 11, 17, 29.— Plenk, Samml. von Beobacht., b. ii.— Plenciz, Aita et Observ. Med., p. 162—Collomb, in Holler's BiM. Chirurg., vol. ii., p. 172.—Eicken, Sammlung, h. i., p. 145.—Chappe, Journ. Gen. de Med., t. xxvi., p. 3bi.— Henkel, Samml. Med. u. Chir. Anmerk.,b. ii.,art. 1, De Home, in Mem. de la Soc. Roy. de Med. ad ann. 1779, p. 300.—Lieutaud, Hist. Anat. Med., 1 ii., obs. 794, 795, 798, 922.—Salle, N. Beytr&ge, b. ii., p. 25.—Stoll, Rat. Med., &c. vol. vii., p. 96.—Baldinger, N. Magazin, b. i., p. 163. 183.—Caldani, in Mem. di Fisica delle Soc. Hal. a Modena, t. xii., p. 2.—Portal, Cours d'Anat. Med., t. iii., p. 354. et seq.—Frank, Interp. Clinic, vol. i., p. 379.—(See the Bibi loo. and Refer, of the arts. Aorta and Pleu- ra.) iv. Hemorrhage into the Peritoneal Cavity.— Tulpius, 1. ii.. cap. 40.—Ballonius, Paradigmala, n. 14.— Bonet, Sepulchretum, 1. ii., sect, x., obs. i.—Bellocq, in Mem. de l'Acad. de Chirurg., t. iii., p. 602.—Ayrault, in Journ. de Medecine, t. xxii., p. 46.—Buttner, Unterricht von der Todlichkeit der Wunden, p. 40.—Eller, Med. u. Chirurg. Anmerk, &c, p. 138.—Ferro. Medic. Ephemer., p. 127.—L. Bourgeois, Obsrrv. Diverses, &c, 1. i., cap. 48. —Matam. De Aneurism. Praecord. Morbis, p. 118.— Peter- mann, Observ. Med. Decus., iii., n. 9.—Saxonia. Pract. Med., I. iii., cap. 32.—Sandifort, Observ. Anat. Pathol., iv., n. 5. —Jenty, Course of Anatomical and Physiol. Lectures, vol. i.. p. 169— Daniel, Samml. Med. Gutachten, 1., p. 79.— Nenei, in Atti di Sienna, t. ii., p. 195.— /. Clarke, in Trans. of a Society fur Improvement of Med. Knowledge, vol. i., art. 14.— G. Blane, in Ibid., vol. ii., art. 2.-7. P. Frank, De Cur. Horn. Morbis, I. v., p. 231.—Erdmann, in Horn's N. Archiv., b. iii., p. 35.—Heim, in Ibid , Jan., 1812, p. 5, et seq.—Portal, Anat. Med., t. v., p. 345.—Osiander, Denk- wurdigkeiten, b. i., p. 122.—(See Bib. of art. Perito- neum.) 279. XI. Hemorrhage into the Areolar Tissue, or into the Substance of an Organ, occurs in two forms : 1st. Confined to a single part or organ ; 2d. Extended to several organs, and more or less diffused. The pathological states of which either of these forms may be the result are chiefly the following: a. Increas- ed determination of blood or vascular action ; b. Active congestion, or engorgement from in- 144 H.EMORRHAGE FROM THE AREOLAR TISSUE. creased flow of blood to the part; c. Passive congestion from interruption to the return of blood from the seat of haemorrhage ; d. Soft- ening, or diminished vital cohesion of the or- gan in which extravasation takes place ; e. Dis- ease of the vessels of the part favouring rup- ture, &c.; /. Laceration or rupture of an organ from concussions or external injuries ; g. Loss of vital tone, expressed chiefly in the extreme capillaries ; h. A morbid state of blood ; and, i. These last two conditions conjoined. The more limited forms of haemorrhage into cellular or parenchymatous parts may arise from either, or from more than one of these pathological states ; but the more diffused or extended de- pends chiefly upon the last three of them. The former may occur primarily, or without any very manifest sign of pre-existent disorder, al- though such disorder actually exists ; the lat- ter is generally the result of very serious and evident disease, especially of scurvy, purpura, putro-adynamic or malignant fevers, &c. The organs in the structure of which haemorrhage most frequently occurs are the brain and cer- ebellum, the spinal chord, and the lungs ; and those in which it is more rarely observed are the spleen, liver, pancreas, and kidneys. It still more rarely takes place in two or more of these parts at once, unless in the course of the dangerous constitutional maladies just men- tioned. M. Robert (Nouv. Biblioth. Med., t. ii., p. 74, 1826) records a case in which he found blood effused in the substance of the brain, lungs, liver, pancreas, and kidneys ; but the pre- existent constitutional disorder was character- ized by extreme adynamia, manifested especi- ally in the vascular system andcirculating fluids. 280. Haemorrhage into the areolar tissue, par- ticularly in those parts of it that possess the membranous form, giving rise to ecchymoses, petechiae, &c, occur chiefly in purpura, scurvy, and the last stages of malignant exanthematous and other fevers ; and in these diseases haem- orrhage generally takes place, also, from mu- cous surfaces, and sometimes, likewise, into the substance of one or more organs. In these ca- ses, the blood is dark, dissolved, or deficient in crasis, and incapable of coagulating. The in- stances of" Universal Hamorrhage" (Ham. Uni- versalis) recorded by several writers of the six- teenth and seventeenth centuries are entirely to be referred to the above maladies, or to a scorbutic conjoined with a haemorrhagic diath- esis, generated, most probably, by the nature of the food and modes of living, and to the pu- tro-adynamic state which exanthematous and typhoid fevers then frequently assumed. (See arts. Apoplexy, Brain, Lungs, Palsv, Purpu- ra Scurvy olc 1 HAEMORRHOIDS. — Syn. Mfioppoic (from alpa, blood, and pooc, a flux), Hippocrates, Ga- len, Celsus. Hamorrhois, Pliny, Linnaeus, Sa- gar, Sauvages, Cullen. Hamorrhoides, Junck- er. Fluxus Hamorrhoidalis, Hoffmann. Proc- torrhaa, Auct. var. Proctalgia Hamorrhoi- dalis, Macbride. Marisca, Good. Hamor- rhischesis, Ploucquet. Hamorrhcea Vasorum Hamorrhoidalium, Swediaur. Hemorrhoides, Flux Hemorrhoidal Fr. Goldadcrfluss, Hdm- orrhoiden, Germ. Morice, Ital. Piles. Classjf.—1. Class, Febrile Diseases ; 4. Order, Haemorrhages (Cullen). 1. Class, Diseases of Digestive Organs ; 1. Order, Affecting the alimentary Canal (Good). II. Class, II. Order (Author). 1. Defin.—Pain, tension, weight, heat, or oth- er uneasy sensation, referred to the rectum arid anus, accompanied or followed by tumours in these parts, or by a flow of blood from them when the pa- tient is at stool; recurring after intervals, and sometimes periodically. 2. Preliminary Remarks.—There are few dis- eases upon which so much has been written— ignorantly and dogmatically written—as upon haemorrhoids. In modern times, the pathology and treatment of this disease have been too generally viewed in a limited point of view, and usurped by persons who have endeavoured to convince the public that they have made it the subject of especial investigation, or even of exclusive study. Judging, however, from their writings, more mischief than benefit has thus arisen from the mechanical division of labour they have adopted; and not only have they failed in advancing our knowledge as to the na- ture and treatment of the malady, with which they profess so intimate an acquaintance, but they have actually overlooked, or been ignorant of the part it occupies in the circle of morbid action, and they have frequently, even when affording temporary benefit by empirical means, or by local or surgical aid, caused most serious consequent mischief. Those affected by this complaint are unable to foresee the consequen- ces that may result from injudicious interfe- rence, especially if appropriate medical treat- ment be not afterward pursued; and, while immediate relief, when procured, is made a matter of high commendation, both by those who receive and by those who administer it, the remote or contingent bad effects are rare- ly traced by them to their origin, and are often of such a nature as to terminate all inquiry. 3. Of those who have professed an infallible cure for haemorrhoids, there have been few who appear, from their writings, to have been ac- quainted with the nature of the complaint; with the relation in which it often stands to other morbid conditions ; with its frequent existence as the more manifest part of a more important and concealed state of disease, and with the most safe and appropriate means of removing it. They have viewed it as a local disorder which is to be cured by local or surgical treat- ment, and not as a visceral disease often de- pending upon latent or extensive morbid con- ditions, to which surgical measures may prove injurious, and for which such measures are, at most, only occasionally required, and then as adjuvants merely of a strictly medical, and oft- en constitutional treatment. Owing to an im- perfect knowledge of the varieties of haemor- rhoidal tumours, and of their pathological rela- tions, a. Fatal haemorrhage has not infrequent- ly resulted from excising or puncturing them; b. Enteritis, peritonitis, and even internal phle- bitis, have followed the extirpation of them by ligature ; and, c. Fatal diseases of the brain, or of the lungs, or even of the liver, have arisen from the permanent stoppage of a discharge by these means, to which the system had become habituated, and which had warded off these and other serious maladies. This evacuation being arrested by these or other local meas- ures, the safety-valve to an overloaded state of the vascular system is permanently closed, HAEMORRHOIDS—General Character and Symptoms. 145 and a source of local derivation and of dis- charge that had preserved a vital organ from impending disorganization is cut off, without either preparing the system for the changes thereby produced, or substituting some other evacuation in its place. Persons who thus ex- tend the division of labour principle to a sci- ence which admits not of it with advantage ei- ther to the branch which is thus attempted to be cultivated, or to those upon whom it is prac- tised, may reply that they have seen no mis- chief result from the means they employ; but the mischief in such cases is strictly of a med- ica. nature, is often remote, and falls not with- in the sphere of those who thus unscientifically and empirically limit the practice of their pro- fession. Division of labour may improve man- ual dexterity, or may extend mechanical con- trivance ; but it cannot improve pathological knowledge, nor illustrate the relations or asso- ciations of morbid actions, nor lead to truly sci- entific, and safe, and appropriate, and perma- nently beneficial modes of cure. 4. I. Pathological History of the Disease. —The term hamorrhoids, signifying literally a flow of blood, was made use of by Hippocrates ; and, down even to the present time, has been applied to a dilatation of the veins at the ex- tremity of the rectum, accompanied with a flow of blood, and the vessels of this part have been consequently called the haemorrhoidal vessels. Many of the ancient and of the older writers have extended the term, not only to every com- plication of this complaint, but also to haemor- rhages from natural outlets ; and thus haemor- roids of the uterus, of the bladder, and of the mouth have been frequently used to denote haemorrhage from these parts. Since the time of Morgagni, the term has been applied indif- ferently to that morbid condition which was generally attributed to dilatation of the haem- orrhoidal veins, and to haemorrhage from the rectum, although some authors have endeav- oured to restrict it to one or other of them. But as the tumours and the flow of blood, Whether appearing separately or in conjunction, arise from the same source, I shall consider them as varieties of the same disease. It will, however, be shown that the haemorrhoidal tu- mours consist of different kinds or modifica- tions of structural lesion, and that either of them may take place independently of, as well as in connexion with a discharge of blood from the anus. 5. i. General Character and Symptoms of Ham- orrhoids.—The first attack is usually slight, and often attended by little constitutional disorder. Slight pain, heat, weight, or fulness are felt at the extremity of the rectum, or about the sa- crum, sometimes extending to the perineum, with obscure tenesmus or pain at stool, often with costiveness, and occasionally with an ir- regular or irritated state of the bowels. The sensibility of the bladder or urethra is frequent- ly, also, increased. After a short time, or in two or three days at most, a slight flow of blood, generally of a bright colour, is observed with the faeces, or smearing their surface. In some persons this flow does not take place, particularly in early attacks ; but when it does, r. is usually critical, and all the symptoms sub- side. When this discharge does not occur, as well as very frequently when it does, one or H 19 more tumours, of varied size, begin to appear within or at the verge of the anus. These tu- mours are preceded by a stinging or pricking pain, which increases as they enlarge ; or are compressed by the sphincter ani. Sometimes blood oozes from their surface, or is squirted out through small apertures when at stool. Occasionally they remain dry, or are moistened by a colourless serum; but in either case they collapse after a short time, and entirely or partially disappear. 6. After a longer or shorter interval the same train of symptoms returns, generally in a great- er degree, and acquires increased severity by the repetition. The pains are more acute, es- pecially when sitting, standing, or walking; and often extend down the insides of the hips and thighs; the blood is discharged in greater quantity; and the tumours, if they have pre- viously been developed, become larger or more numerous. Subsequently, when they collapse, and particularly when they have been often distended, they present so many flaps of skin, and, when external, form a serrated margin to the anus. 7. In irritable or weak persons, especially when the complaint is simple or primary, is se- vere, or returns often, the local alteration af- fects more or less the general health. Fre- quent chills or coldness, alternating with flush- es, dryness of the mouth, hardness or frequen- cy of pulse, costiveness, pallor of the counte- nance, and other febrile symptoms are com- plained of. The functions of digestion are also more or less deranged, and the bowels are ei- ther costive or irregular, especially when the complaint is dependant upon disorder of the hepatic organs. When it is associated with disease of the lungs, the symptoms referrible to the chest are generally materially alleviated by it, especially if it be attended by sanguine- ous discharge ; and a similar result follows its occurrence in plethoric persons liable to head- aches, or to congestion of the brain or liver. In all cases, however, care should be taken not to mistake the constitutional disorder, or the af- fection of remote organs, often occasioning the disease, for sympathetic disturbance preceding the haemorrhoidal attack. A minute examina- tion of the relation of the complaint with other ailments should always be instituted before the indications of cure are determined upon. 8. Such is the usual course of haemorrhoidal attacks ; but the sense or weight, heat, fulness,, or constriction, with more or less pain about the anus, and slight constitutional disturbance occasionally occur without either effusion of blood or the formation of tumours, even in old cases; and the haemorrhage sometimes takes place without the tumours, but seldom without being ushered in by the other symptoms. In- deed, in all cases, indications of congestion, or of increased action of the vessels of the -part are present in some degree, these states of the vessels constituting a principal feature of the complaint. Both the local and constitutional symptoms, and the structural lesions, show that increased determination of blood to the extreme vessels of the part in most cases, and impeded return of it from them in others, are the chief pathological conditions of the disease. 9. ii. Of the Hamorrhoidal Tumours __The nature of these tumours was not understood 146 HAEMORRHOIDS—Consequences and Complications. until lately. They were usually distinguished into internal and external, and into bleeding and blind piles, according to their situation in re- spect of the verge of the anus, and to their con- nexion with a sanguineous discharge. But most of the older writers and many of the mod- erns, and among the latter the Bells, Homk, Baillie, Cooper, &c, imputed them to dilata- tion of the veins. More correct views as to their structure were entertained first by Le Dran and Richter, perhaps also by Cullen and Abernethy ; and more certainly by Chaus- sier, De Larroque, De Montegre, Calvert, and Colles. From my own observations, as well as from the researches of these and other pathologists, hereafter referred to, there are three kinds of haemorrhoidal tumours, differing essentially both in their structure and appear- ance.—a. The first, or most common kind, is first seen in the form of fleshy tubercles of a brownish or pale-red colour, situate within the anus, or descending from the rectum. They have a somewhat solid or spongy feel; and, when divided, they present a compact or po- rous and bloody surface. As the blood oozes from the cut surfaces, they become pale and flaccid. When the tumours are external, they are paler and more elastic ; are infiltrated by serum ; and are sooner produced, and disap- pear more readily than when they are internal. In either case, they often contain a central cavity filled with fluid or coagulated blood, of a dark colour. This cavity is either smooth or granulated, and minute vessels may be traced into it; Mr. Calvert states that it has no di- rect connexion with any larger vessels. It is usually small; generally about the size of a pea, but sometimes that of a bean or walnut, or even larger. More frequently, however, there is no regular cavity or cyst; the substance of the tumour being as if infiltrated with blood, which becomes coagulated and dark; but this appear- ance is not owing to extravasation, but rather to dilatation of a number of small vessels which traverse the tissue in the direction of the axis of the rectum, as, upon dividing the part longi- tudinally, numerous dark streaks are seen in its substance, while a section made transverse- ly shows only small, roundish specks. 10. The patient is usually made sensible of the development of these tumours by a pecu- liar pricking or stinging sensation, within or at the margin of the anus ; and one or more are found slightly elevated, or pressed downward by the sphincter. The increase of these tu- mours takes place more by elongatiou than by expansion, and they assume a conical form, and are larger than their necks. Sometimes blood is exhaled from their surface ; in other cases, or on other occasions, a serous fluid is exuded ; and occasionally they are entirely dry, especially when they are external. In either case they generally disappear in two, three, or four days, but return again at an uncertain or at a regular period, and increase in size, be- coming firmer in texture. After some blood is •evacuated from them, or after the determina- tion of blood to the parts has ceased, they col- lapse, leaving small pendulous flaps of skin, which ultimately disappear if the tumours have been small; but if they have been large, these [flaps continue conspicuous, and give a project- ing and irregular margin to the anus. Having been strangulated by the sphincter, or repeat- edly engorged with blood or lymph, or chroni- cally inflamed, these tumours become more solid and almost permanent, are a source of constant discomfort, and give rise to several of the consequences and complications about to be noticed (y 20). 11. The permanent state of the tumours is owing partly to the development of capillary vessels, and partly to the effused blood and lymph becoming organized ; this latter circum- stance, especially, giving rise to the excres- cences or irregular mass of tumours found around the anus in those subject to haemor- rhoids. Occasionally the tumours acquire a very great size, arising from the effusion of much blood in the central cavity, and of blood and lymph in the cuticular envelopes. In- stances of the enormous size of these tumours have been recorded by Schmucker, Calvert, and other writers about to be referred to. 12. b. Haemorrhoidal tumours formed by a varicose state of the veins of the rectum are not so common as those just described. They seldom attract attention until they have made some progress, for the distention takes place very gradually, without causing much sympathetic disturbance, or materially increasing previous disorder. They are not so disposed to enlarge at particular periods, and are more permanent and less painful than the form already noticed. They are commonly of a dark or bluish colour, and soft and elastic to the touch. When com- pressed by the finger they become sensibly less, but return to their former state when the pres- sure is removed. They are round and broad at the base, and often distributed in irregular or ill-defined clusters. They evince little dis- position to bleed, unless when ruptured or in- jured. They appear crowded together, extend up the rectum, are more or less internal, or become external chiefly during costiveness, or when the patient is straining at stool, or after a faecal evacuation ; while the former kind is limited, and generally external, or within the reach of the finger. Valsalva, Ludwig, Petit, Richerand, Begin, Calvert, and others have seen haemorrhoidal varices extend upward along the rectum to the colon, especially in per- sons who had experienced obstruction of the portal circulation. M. Begin observes that, in most cases, the dilated, superficial, submu- cous, or subcutaneous veins are only the small- er part of those surrounding the rectum. Some- times the lower part of this intestine appears as if plunged in the middle of a network of di- lated and engorged veins, forming a thick vas- cular ring, the incision or puncture of which may give rise to dangerous haemorrhages. M. Richerand found, upon dissection, those vari- cose tumours filled with clotted blood, and their interiors continuous with those portions of the veins which retained their usual size. These dilated vessels presented alternately a state of distention and their natural caliber, and were continued in every direction, forming a plexus around the outlet of the bowel, the dilated por- tions being covered only by the thinned mu- cous membrane. 13. As the varicose tumours arise from many of the causes that produce the preceding form (Y 9), and as both varieties occupy nearly the same situation, it may be reasonably inferred HaEMORRHOIDS—Discharges from. 147 that they may exist together, or that the latter may often give rise to the former in connexion with it. Now this is sometimes the case ; in- flammatory irritation supervening in the course of the varicose form of the disease, superin- ducing the marisca, or the first variety of tu- mour, and thereby obscuring the varicose char- acter of the former. Or a different procedure, as Mr. Calvert supposes, may take place ; the veins becoming dilated in consequence of the previous formation of the cellular tumours. These complications of the tumours can be as- certained only by a careful examination, and by attention to the history, progress, and symp- tomatic relations of the case. 14. c. A third form of haemorrhoidal tumours, of an erectile character, was first noticed by Sir Jamks Earle, and more particularly described by Mr. Colles. These tumours are of differ- ent sizes; are soft and spongy to the touch, of a purplish colour, with a number of minute but distinct vessels on the surface of each. One, two, or more of these tumours protrude through the anus when the patient is at stool. Early in the disease the protruded parts retire spontaneously; but, in advanced stages, they require to be replaced by the hand. Alvine evacuation is followed by pain, which, especial- ly when the disease is prolonged, does not cease for two or three hours, and is attended by losses of blood, which sometimes occasion exsanguine exhaustion, the sphincter ani be- coming wide and relaxed, and the tumours pro- truding. Dr. Colles states that, on examina- tion after death, he found blood-vessels as large as crow-quills, running for some way down the intestine, and then dividing into a number of branches ; each of these vessels ramifying pro- fusely, and each forming, by the interlacing of its numerous branches, one of these erectile or vascular tumours. The trunks and branches of these vessels were covered only by the lining membrane of the intestine. [The late Dr. George Bushe, of New-York, thus speaks of haemorrhoidal tumours : *' I have repeatedly injected these tumours with coloured water, both from the arteries and the veins, and when cut into while the fluid was injected, small jets were observed to issue from many points. I have frequently dissected them with the greatest ease, and found that they were spongy, reddish, and contained both arter- ies and veins, the latter being most copious, but always perfectly healthy."* Dr. John Watson, of New-York (New-York Journ. of Med. for July, 1844). states that, so far from finding the veins in haemorrhoidal tu- mours " healthy," he has often observed them not merely distended enormously beyond their natural size, but tortuous, convoluted, and thrown into irregular pouches, with their coats thickened, the blood within them coagulated, and the cellular tissue surrounding them hyper- trophied and consolidated, precisely as we see in some of the worst forms of varices in the veins of the limbs. Dr. W. also remarks, " On one occasion, in which I assisted Dr. Stevens in an operation for the removal of an immense protrusion of the anus, depending on a vast number of hsem- * l £ Treatise on the Malformations, Injuries, and Dis- Mies of the Rectum and Anus," by Georoe Bushe, M.D. n«w-l(ort, 1B37, p. 182.] orrhoidal tumours that lay beneath the surface, and in which the parts were removed by ex- cision, I took occasion to examine the diseased structure carefully. After the excision, the exposed surface bled profusely. The haemor- rhage was checked with difficulty, and only after repeated and protracted efforts with the tampon, in which the patient appeared to suf- fer infinitely more than if ligatures had been applied. On inspecting the well-exposed bleed- ing surfaces in this case, I could readily distin- guish the minute capillary arteries pouring out their delicate jets of red blood from the num- berless dilated veins, each of the size of a crow-quill, or larger, which gave the whole surface the perforated appearance of the top of a watering-spout, and from which issued a torrent of venous blood. I took occasion after- ward to examine the mass that had been re- moved. After it had lain a day or two in diluted alcohol, the dilated veins on its surface had contracted nearly to their primitive size; but, on tracing them inward, I found them communicating with pouches at least the sixth of an inch in diameter, which, when dissected from the surrounding parts, might, in size and form, be compared to small leeches. Many of these pouches communicated with a capillary vessel at either extremity. Their coats were rather thick; they were filled with coagulated blood ; they were very numerous, pressed upon one another in all sorts of ways, and were held together by thickened and indurated cellular tissue. They were, in short, varicose pouches, formed in the course of the haemorrhoidal ves- sels, just as such pouches are seen to form in the branches of a varicose saphena vein, only more numerous, and in closer apposition than is usual in the latter case."—(Loc. cit.)] 15. iii. Of the Hamorrkoidal Discharges.—A. The ancients believed the blood to be dischar- ged from the tumid extremities of the haemor- rhoidal veins. Morgagni found these veins more or less dilated in several cases, and it was very generally considered that the blood oozed through, or proceeded from rupture of these vessels. The investigations of modern pathologists have satisfactorily shown that the haemorrhage may arise from various sources: 1st. From congestion of the vessels of the part, followed by exhalation or exudation from the internal surface of the rectum ; 2d. From irri- tation of this bowel, followed by vascular de- termination and sanguineous exhalation ; 3d. From the surface of the haemorrhoidal tumours, especially those belonging to the first and third varieties; and, 4th. From the rupture of vari- cose or enlarged vessels. When the blood proceeds from theirs* or second of these sour- ces, it may be seen to exude from the surface of the protruded portion of bowel; and the discharge generally removes all the symptoms characteristic of the complaint. It is also fre- quently preceded and followed by an exhalation of a serous nature from the same source. Haemorrhage, in connexion with the common form of tumour, may arise from exhalation from its surface; or from the contraction of the sphincter forcing blood, in a fine stream, from one or more points of it; or from exha- lation from the adjoining mucous surface, in consequence of congestion of, or of sanguineous determination to the affected bowel Where 148 HaEMORRHOIDS—Consequences and Complications. the vascular or erectile tumours exist, blood is always discharged, and uniformly from their surface. The varicose form of tumour is less frequently attended by haemorrhage than any of the others. When the blood proceeds from the rupture of enlarged or varicose vessels, it generally flows in a stream while the patient is straining at stool, the flow increasing or re- turning when this effort is repeated. The pas- sage, also, of hardened faeces over the congested or inflamed mucous surface of the rectum, or over the tumours developed beneath this sur- face, or over the enlarged or distended vessels, may lacerate or injure them in such a manner as to be followed by haemorrhage, but in such cases the discharge is usually slight. 16. In many cases the blood flows for a short time only, and is not again seen until the next attack ; but in others it is observed re- peatedly when the bowels are acted upon, or the discharge is renewed, when the faeces are expelled, for several days. It is generally of a red colour, and either covers or follows the faecal evacuation; but when it is consequent upon venous affection or dilatation, it is of a dark hue, and follows, or is partially mixed with the faeces. 17. B. The returns and amount of the hamor- rhoidal discharge are extremely various, but in many instances a periodical return is observed in both males and females. In females the haemorrhoidal not infrequently takes the place of the catamenial discharge, especially at the age when the latter usually ceases, and assumes a periodic form. In some instances these evac- uations alternate. When the morbid action has once commenced in this part of the body, it being favoured by peculiarity of structure and by several pathological relations (Y 30), there is always a predisposition thereby formed to the recurrence of it; and the same causes still operating, it at length becomes habitual, and even necessary to the prevention of more serious maladies. It has been satisfactorily shown by observation that, as long as the caus- es of haemorrhoids continue, the evacuation attending them is a wholesome occurrence, inasmuch as an overloaded state of the vascular system, that would otherwise induce dangerous visceral disease, is thereby removed. In all cases, therefore, when haemorrhoidal affections depend upon constitutional causes, or are con- nected with any indications of visceral disease, or have existed for a considerable time, their return should not be prevented, unless other sources of discharge, or other sanguineous evacuations are substituted for them; but when they proceed from causes which are chiefly or entirely local, neither the vascular system nor constitution, nor any important in- ternal organ manifesting disorder, a more ac- tive interference may be attempted, although even then with caution, especially if there be any tendency to vascular plethora, and if the principal causes of the disease are still in oper- ation. 18. The quantity of blood lost in each attack may be very trifling, may not exceed a drachm or two ; or it may amount, at one time, to sev- eral pounds. Instances are adduced by Rho- dius, Fernelius, Lanzoni, Harris, Spindler, Moehring, Hoffmann, Earle, Calvert, and others, in which the quantity discharged deem- ed enormous. Mr. Calvert supposes that the vessels in such cases are in a state of extreme excitement; but this is by no means a correct inference, as in most cases of excessive dis- charge the haemorrhage is passive or venous, or is consequent upon congestion, or upon in- terrupted circulation through the haemorrhoidal vessels. The evacuation more commonly is excessive from its frequent return than from its quantity at any one time ; and it not infre- quently induces a state of exsanguine exhaus- tion, requiring the most decided interference. 19. C. A colourless Hamorrhoidal Discharge —Mucous or Serous Hamorrhoids (H. mucosa vel serosa) of authors ; Hemorrhoides blanches, Begin ; Medorrhaa Ani, J. P. Frank—some- times takes place, and either follows the dis- charge of blood, or attends the haemorrhoidal tumours, especially those belonging to the first variety. It varies much as to quantity and ap- pearance. It is either watery or mucous, or resembles a weak solution of gum, or it is al- buminous and like the white of egg. When watery, serous, or mucous, it usually exudes slightly from the anus ; when more abundant or albuminous, it is commonly passed at stool. In cases attended by much heat and irritation about the anus, a colourless exudation, consist- ing chiefly of an increased secretion from the follicular glands of the part, takes place. These varieties of colourless discharge are most fre- quent when there is little or no haemorrhage, and when the disease is associated with ascar- idcs, or with leucorrkaa, or with pregnancy. 20. iv. Of the Consequences and Complications of Hamorrhoids, local and constitutional.—A. In- flammation is one of the most frequent morbid associations of haemorrhoids. It is attended by more or less swelling and redness of the lower part of the rectum and anus ; by throb- bing, and by increased sensibility and heat, ag- gravated by the passage of faeces. The san- guineous discharge is slight or absent, but if it become abundant the symptoms subside. A mucous discharge is, however, not uncommon. Sometimes the inflammation is severe, and implicates not merely the mucous membrane and subjacent cellular tissue, but also, in a slighter degree, the prostate gland and neck of the bladder, occasioning much pain in the perineum, sacrum, &c., with dysuria, or even strangury. The irritation may even extend to the womb in females. The tumefied state of the lower part of the intestine in these cases, together with the inflamed tumours, and the spasmodic constriction of the sphincter, pro- duces obstinate constipation and straining or tenesmus. Not infrequently the protrusion of the tumours, when internal, with a portion of the mucous membrane, follows the action of the bowels, and the inflamed tumours, being strangulated by the sphincter, become remark- ably painful, or even ultimately slough. With the severity of the local symptoms, the consti- tution generally sympathizes; and febrile symp- toms are developed, particularly in irritable or nervous temperaments. 21. B. Fissures or rhagades of the anus are not uncommon in cases of haemorrhoidal tu- mours. They may commence in small longi* tudmal ulcerations ; but they more frequently seem to take place as follows: When the tu-i mours are large and numerous, hardened faecal HaEMORRHOIDS—Consequences and Complications. 149 matters, in passing forcibly between them, crack or slightly tear them at their bases, the chronic inflammation in this situation harden- ing and rendering the tissues less yielding to any distending power. These fissures are most apt to occur when the tumours are situated upon the sphincter. They are usually slight at first, but they enlarge, owing to the frequent operation of the causes that produced them and to the lodgment of faecal matters, and oc- casion great pain, which continues for some hours after each stool, and spasmodic constric- tion of the sphincter. Herpetic or other chron- ic eruptions sometimes also appear about the anus, and favour the supervention of these fis- sures, by rendering the surface harder and less capable of distention, or by diminishing its vital cohesion. Fissures of the anus mostly occur as a consequence of the first and third variety of haemorrhoidal tumour. 22. C. Ulceration or abscess, frequently pass- ing into fistula, often follows haemorrhoids, par- ticularly when inflammation occurs. When the inflammation is superficial, affecting chiefly the mucous membrane, it gives rise to ulcera- tion in one or more points, especially in the situation of the tumours ; and it may penetrate deeply, or be followed by small abscesses, either in these tumours or in their vicinity. When the inflammation is more deeply seated, impli- cating the cellular and adipose tissues, an ab- scess then forms very readily, and often rapidly. Pain, tension, and heat about the anus are then severe, and with the throbbings extend up the pelvis. When the abscess is anterior to the anus, and presses upon the urethra, and parts adjoining the neck of the bladder, the suffering is very great, and sometimes is attended by strangury or total retention of urine. The ab- scess, in the female, occasionally extends to one of the labia, or even breaks into the vagina, or passes into fistula in that or in an adjoining situation. Of this I have seen several instan- ces. (See art. Rectum ) [Such cases, according to Dr. Burke, are far from being uncommon, and are too often over- looked. To detect these small fistulae, the fin- ger ought to be cautiously introduced, and after a little exploration, a small depression, marking the fistulous orifice, may be discovered on each tumour thus affected. But should this attempt fail, the buttocks may be forcibly separated by an assistant, while the patient bears down; then, with a strong light and a probe of a small size, the sinus will be easily found. Dr. B. states that in a majority of cases but one tu- mour is fistulous.] 23. D. Hamorrhoidal tenesmus, or spasmodic constriction of the sphincter, frequently with pro- trusion of the mucous coat of the rectum, is a com- mon complication of haemorrhoidal affections, particularly when the tumours are inflamed, or when there are fissures between them (v 21). If the tumours are seated within, or above the sphincter, or if the mucous or sub-mucous tis- sues are much tumefied or infiltrated by inflam- matory determination, the actions of the parts of the bowel above this, or the efforts at expel- ling faecal matters, are attended by much tenes- mus, and often cause a protrusion of the tu- mours and tumefied parts, sometimes to the extent of partial invagination of the rectum. When the sphincter is spasmodically constrict- ed, in consequence either of the irritation of the internal surface of the intestine, or of fis- sures in the anus, the veins are grasped so firmly by it as to give rise to a congested or varicose state of those external to or below the constriction, and the disease is thereby aggra- vated and prolonged. This irritable or spas- modic state of the sphincter may exist in ner- vous persons, without fissure or inflammation, and be attended by great pain, as shown by M. Dupuytren ; but it most commonly is associ- ated with one or both of these morbid states, as well as with a bloody or colourless discharge, and with haemorrhoidal tumours, or with either of them only. 24. E. The pain of hamorrhoids varies in character in different cases. In some it is con- stant ; aggravated upon passing a motion, and is attended by heat and throbbing : it is then owing chiefly to inflammation. In others it is intermittent, extremely severe at times ; comes on and ceases suddenly ; is eased by pressure ; and is of a nervous character. This kind of pain is often connected with spasmodic con- striction of the sphincter, and was denominated proctalgia by Sauvages. The pain is often, also, connected with fissure, as shown by Boyeu, Merat, Montegre, and others; and is then pungent, lancinating, cutting, lacerating or pe- culiar, and greatly aggravated by the action of the bowels. In many cases, the pain extends to the insides of the hips and the back of the thighs, or to the urinary organs and urethra, and occasionally up the pelvis into the abdo- men. Indeed, colicky pains, often of a severe kind, usher in an haemorrhoidal attack, as well as supervene in its course, or upon certain modes of curing it, as upon the application of ligatures on the tumours. [The constant pain, tenesmus, strangury, and dysury which these tumours produce wear the patient down, giving rise to sleeplesness, anxiety, and fever, and, in some cases, so ex- cruciating is the pain that the patient must remain perfectly tranquil, as the least motion exasperates his sufferings to an intolerable de- gree.] 25. F. Irritation or inflammation of the neck of the bladder and prostate ; painful affections of these parts of the urethra, and of the vesicula; seminales ; difficult or painful micturition ; re- tention of urine ; and prolapse of a portion of the rectum, are not infrequent complications of haemorrhoids. As more remote consequence* of the disease may be mentioned, fistula in ano, recto-vaginal fistula, induration and thick- ening of the surrounding cellular tissue, per- manent stricture of the rectum, and chronic or constant prolapsus ani. These, and some other organic lesions consequent upon haemorrhoidal attacks, are fully described in the article Rec- tum.* * M. Monteore has given the following- classification of haemorrhoidal complaints : 1. Blind or Dry Haniorrhoids (Caca). f White Discharge (Alba), with Catarrh 2. Hamorrh. with of the Intestines. Discharge (Flu-i Sanguineous Dis-( „ „ , , . entes) - - - . charge (Sangui-! $> Exhalation. I nolenta) - - - ) BV R»l"ure. 3. Hamorrh. with (VaTico'e < Varic<* \ B&'ding. lZ°e7 - - . . - i Bleeding from di> ' ( latedPore.. 150 HEMORRHOIDS—Diagnosis—Causes. 26. II. Diagnosis.—a. Haemorrhoids may be confounded with Intestinal Haemorrhage (v 185), but in that disease the local symptoms and lesions characteristic of haemorrhoids are not present in a prominent or primary manner ; nor can a varicose state of the vessels, nor any other form of tumour, be detected, upon exam- ining the rectum with the finger. Besides, in- testinal haemorrhage is more generally a symp- tom of an acute or dangerous visceral disease, and more frequently appears in the advanced stages of adynamic or other fevers, or as a symptom of non-febrile cachexia, than the haem- orrhoidal discharge, while this latter is more commonly the principal and most manifest, if not the primary affection. It may, however, sometimes happen that a patient subject to haemorrhoidal affections is seized with low fe- ver, or with remittent or simple fever, compli- cated with congestion or obstruction of the liv- er, with or without jaundice, and haemorrhage from the bowels supervenes. The question is, whether, in either of these cases, the blood is discharged from the intestinal mucous surface (see arts. Fevers, § 474, and Haemorrhage, § 185, 196), or from the haemorrhoidal vessels or tumours (Y 15). These are not uncommon cases: I have seen several. A fatal instance of this kind occurred in my practice while wri- ting this article. The diagnosis is of impor- tance, as the prognosis and treatment are both affected by it. If pain, tumours, or other symp- toms referrible to the rectum or anus are pres- ent ; if they be increased by the action of the bowels, and the blood discharged at that time appear fluid and recently extravasated ; and if an examination of these parts, as far as it can be accomplished, show the presence or increase of haemorrhoidal disease, then the haemorrhage proceeds from it; but if the blood be clotted, very dark, mixed with the secretions or fances, or consist of small coagula, the calls to stool not being attended by any distress, the source of the discharge is above that which is the seat of haemorrhoids, and the examination post-mor- tem will show the accuracy of the inference. 27. b. Haemorrhoidal tumours may be con- founded with fungous or polypous tumours or ex- crescences of the rectum or anus ; but these lat- ter enlarge progressively, their surfaces are in- dolent, and they rarely give rise to haemorrhage, or to paroxysmal attacks resembling haemor- rhoids, or to inflammation of the adjoining parts. Venereal excrescences about the anus may be ascertained by the history of the case, by their development exteriorly to the rectum only, and by the morbid appearance of their surface. The slightest observation and the least experi- . Painful Ham. (Dolentes) • • . Hamorrh. with r Constriction of the Anus (cum Contractione A- Inflammatory. Nervous. Fissured. nil Indolent. sues. From Induration of the Tis- 1 Spasmodic. Scirrous. 6. Hamorrh. with . Ulceration (Ul-1 cerata) - - • ( 7. Hamorrh. with e Prolapsus (cum} Procidentia Ani) I 8. Hamorrh. with r Irritation of the f Bladder (cum Ir-i ritatione Vesica Urinaria) • (, Superficial. Fistulous. Frpm elongation of the internal Mem- brane. From Invagination of the Intestine. With Dysuria. Strangury. Hematuria. ence are sufficient for the diagnosis in these cases. [These tumours may also be confounded with prolapsus of the mucous membrane of the rec- tum, especially that chronic affection in which a flap of the mucous membrane, on either side, is forced down, and becomes thick and rugous. The semilunar form of these flaps, the extent of their base, our ability to glide the folded membrane between the finger and thumb, as well as their freedom from haemorrhage and erection, are characters very different from those which belong to haemorrhoidal tumours.] 28. III. Causes.—a. The antecedent or pre- disponent causes of hamorrhoids are tempera- ment, and constitution, age, sex, climate, and modes of living. Persons of a melancholic, bilious, or sanguineo-bilious temperament, of a plethoric habit of body, and with a venous sys- tem prominently developed, are most liable to this disease. The remark of Stahl, that " sub- jects accidere solet facilius hicfluxussanguin- eo-cholericis, et sanguineo-melancholicis pleth- ora affectis," is very near the truth. Owing to this predisposition, the complaint is often hereditary, as fully shown by Haller, Alberti, Larroque, Montegre, and others. It is most common in mature age, when the abdominal viscera are in a state of greatest activity, and the vascular system most plethoric, and, con- sequently, when these viscera are most liable to disorder and to vascular determination. When it occurs in early puberty or soon after- ward, it is chiefly owing to the determination of blood to the vicinity of the rectum, often fa- voured or induced by excessive venereal indul- gences. Haemorrhoids seldom appear before puberty ; and yet I have seen several instances of it in children. I very recently prescribed for the disease in a boy of five years. Trnka, Alberti, and many of the authors referred to adduce similar cases, most of which they im- pute to hereditary disposition. Authors differ as to its greater prevalence in males or in/e- males. Much depends upon the circumstances in which the latter are placed; but it is more frequent in females about the period of the ces- sation of the catamenia, and afterward, and du- ring pregnacy, than at any other time; and these and other circumstances may render it almost, if not quite, as frequent in them as in males. M. Montegre supposes that it is more common in females in an accidental or occa- sional form, and in males in a regular or con- stant manner. [We believe that this disease is far more prevalent in males than in females, previous to the cessation of the menstrual flux in the lat- ter ; but after that period females are more li- able to it than males] 29. Climate has some influence in disposing to the complaint. Warm, moist, and miasma- tous climates are much more favourable to it than those which are dry, cold, or temperate. The former develop the bilious, melancholic, and choleric constitutions, relax the venous system, and favour obstructions of the abdom- inal viscera, changes most conducive to haem- orrhoids. Much, however, will depend upon the modes of life, the manners, and the morals of the inhabitants. [We agree with Dr. Bushe in opinion that changeable weather, such as we experience in this country especially, is a HaEMORRHOIDS—Prognosis. 151 frequent source of haemorrhoidal affections. There is no more frequent disease, perhaps, in the United States than the one under consid- eration ; and there can be no doubt that it is frequently induced by the frequent and sudden accumulation of blood in the internal organs, when the surface of the body, which has been hot, becomes rapidly cooled by the sudden re- duction of temperature. " The spring," says Dr. B., " is the period most favourable to the development of haemorrhoids ; first, because the mass of the blood is increased in conse- quence of the secretions having been diminish- ed during the winter; secondly, because the absorption of caloric expands the blood ; and, thirdly, because the phenomena of life are more active at this season."] Habits of life exert the greatest influence in causing the disease. Sedentary occupations, and indolence with lux- urious nourishment, must, as Dr. J. Johnson remarks, either find some outlet to the super- abundant fluids, or bring on a train of diseases. Haemorrhoids and gout are the common con- sequences of this state of things. Many peo- ple who have led an active life for many years, on leaving off business and indulging in repose, become, for the first time, affected with piles. The sitting posture, retained for many hours in succession, or habitually, particularly on warm or soft cushions ; full or rich food ; heating or stimulating diet, and intoxicating beverages; inordinate excitement of the sexual organs ; habitual constipation, and the use of warm or irritating lavements, and strait corsets, not only predispose to, but often also directly produce this complaint. It is owing to the association of several of these causes that piles are so common among persons occupied at the desk, and among tailors and shoemakers, as well as among the inhabitants of Turkey and of other Eastern countries. It has been very often re- marked that haemorrhoids are more prevalent in spring and summer than in winter ; and this appears to be the case. A disordered state of the alimentary canal and of the liver, and the suppression of other discharges, have a great influence in favouring an attack. 30. b. The occasional exciting causes are, 1st. Whatever inordinately excites the rectum and lower part of the colon, particularly too large or too often-repeated doses of calomel, aloes, colocynth, black hellebore, camboge, or scam- mony ; occasionally, also, of rhubarb, the neu- tral sulphates, and of any other purgatives in- judiciously prescribed or exerting a drastic ac- tion ; the passage of acrid bile; the irritation caused by worms; many of the substances said to be emmenagogue ; all the preparations of mercury in large or frequent doses ; the liquor arsenicalis, when thus employed; and the in- appropriate use of chalybeates ; 2d. Whatever prevents the return of blood through the haem- orrhoidal veins, as constipation, the lodgment of hardened faeces in the rectum or lower parts of the colon, and repeated efforts at evacua- tion ; torpor, congestion, or structural lesions of the liver, and obstructed circulation through the portal system ; the pressure of a pregnant, enlarged, or displaced uterus, or of a diseased ovarium; and disease of the prostate or sphinc- ter ani; 3d. Whatever excites and determines an increased flow of blood to the sexual and urinary organs, as venereal excesses, spirituous liquors, the irritation of calculi, of cantharides, &c.; 4th. External irritation of adjoining parts; prolonged walks in hot weather; riding in coach- es, or on horses or mules without a saddle : " Nam solet a nudo surgere ficus equo" (Mar- tial, 1. xiv., epig., 85), and the frequent applica- tion of leeches to the anus ; and, 5th. The lo- cal influence of cold or warmth, as sitting on the ground, or on stone seats or on damp cush- ions, and the habit of standing with the back to the fire. Besides the foregoing, various other circumstances occasionally cause this com- plaint, as the more violent mental emotions, both exciting and depressing ; errors of diet and of regimen; inordinate excesses of any kind; and diseases of other organs, particularly those of the lungs or liver. Haemorrhoids are, more- over, sometimes critical in other maladies, es- pecially in fevers and in inflammations of the brain, or of any of the viscera lodged in the thoracic and abdominal cavities. Owing gen- erally to the association of several of the above causes, this complaint is very common in the upper classes of society, in both its simple and more complicated states ; and hence the num- ber of treatises which have appeared on it and its consequences. [There is one cause peculiar to females about the period of the change of life, and that is the cessation of the natural menstrual discharge, in consequence of which, especially in plethoric women, the system becomes surcharged with blood. If, under such circumstances, the ves- sels of the rectum exhale the superfluous blood, it may be looked upon as a fortunate occur- rence, for in this way fatal attacks of apoplexy and other diseases are warded off] 31. IV. Prognosis—A favourable opinion of the result may generally be entertained in all the simple states of this affection, particularly when the patient is not far advanced in life, when the constitution is not in fault, and when the lungs, the liver, and brain present no ten- dency to disease. In other circumstances, and when the complaint is periodic, the removal of it, however cautiously effected, may be follow- ed by serious effects, and especially by diseas- es of the lungs. (See v 3, 30). In all cases the prognosis should be founded upon a knowl- edge of the causes, of the form, and of the com- plication of the disorder. If the causes be not obviated, either the disease will return after a time, or it will be followed by a more serious malady. The extent and frequency of the dis- charge must always be taken into account, as well as the form of haemorrhoidal tumour. The more common variety of tumour is seldom at- tended by any risk, unless in the circumstan- ces just alluded to, or when otherwise compli- cated, locally or constitutionally. But the var- icose tumours require a more cautious or re- served opinion ; for, under the most judicious management, the more prominent or distended parts of the vessels may burst by a thinning process, and occasion profuse haemorrhage. They are also generally connected with more or less visceral disease or constitutional disor- der. The prognosis should not be materially different from that just stated, when the com- plaint is complicated with inflammation, for some one of its terminations, as abscess, ulcer- ations, or fissures between the tumours, fistula, spasm of the sphincter, prolapsus or invagina- 152 HAEMORRHOIDS—Treatment. tion of a portion of the bowel, and even per- manent stricture of the rectum, may take place, however judicious the treatment may be, and occasion very great or prolonged suffering, if not imminent danger. When the complaint is connected with visceral disease, and especially with pulmonary disease, the opinion should be formed chiefly with reference to this associa- tion, and the haemorrhoidal affection should be so managed as to prove a derivation from the internal malady, and to prevent its increase. 32. V. Treatment.—A. The propriety of sup- pressing the hamorrhoidal discharge ought always to be considered when entering upon the treat- ment of it. Cullen erred egregiously in con- sidering the complaint as generally local, and in recommending a local treatment; and in this he has been too closely followed by surgi- cal writers. This practice, as Dr. J. Johnson observes, of removing the disease as speedily as possible, is very well in sound constitutions ; but where there is any defect in the system or organ predisposed to disease, we should be careful in avoiding the sudden stoppage of the haemorrhoidal movement or discharge. Hip- pocrates observed that this complaint often protected the system from other maladies ; and a similar opinion has been offered by Stahl, Hoffmann, Alberti, Rosen. Richter, and oth- ers. This is especially applicable to persons who are liable, hereditarily or otherwise, to gout, consumption, apoplexy, palsy, or other kinds of haemorrhage. Mr. Howship states that a gentleman, subject to periodic haemor- rhoids, was induced by a quack, and in oppo- sition to the regular opinion, to have recourse to a strong vitriolic wash. This cured the dis- charge, but the patient died soon afterward of gout in the stomach. M. Montegre adduces proofs of a number of diseases having been produced by the suppression of piles ; the most common of these being fevers,* haemorrhages, inflammations of the lungs or pleura, phthisis, apoplexy, and various other internal and organ- ic maladies. Mr. Calvert saw gastric fever follow the application of cold water to the anus for haemorrhoids. I was lately consulted in a case of apoplexy consequent on the stoppage of the discharge, and, some years since, in a case of fever, and in another of melancholy from this cause. 33. B. Constitutional Treatment.—The often- er the haemorrhoidal attack is renewed the more liable will it be to recur, and the greater will be the risk of effecting a sudden cure. On this account, it is most desirable to ascertain the causes of the complaint, and to remove * A gentleman, between fifty and sixty, who had suffered long from hemorrhoids and prolapsus of the mucous mem- brane of the rectum, had remained free from the complaint for a considerable time, in consequence of using cooling as- tringents, &c, locally, as advised by a person who had de- rived benefit from them. I was called to him, and found him labouring undei a most dangerous form of fever, com- plicated with deep jaundice, and attended by a conviction of approaching dissolution. His pulse was upward of 120, •soft, small, and weak. His bowels were relaxed, the stom- ach irritable, and the evacuations white. He had been at- tacked only the day before, and was restless and despond- ing. Calomel with camphor; effervescing draughts with the carbonate of soda in excess ; Seltzer water with old wine ; laxative enemata, and various other means, both in- -ternal and external, were prescribed according to the rapid progress of the malady. On the third night he became de- lirious ; soon afterward comatose ; and, although the hem- orrhoidal discharge returned, from the use of the calomel, he died on the eighth day of the disease. Inspection of the body was not permitted. them, as being most necessary, not only to thr1 efficacy, but also to the safety of the treatment. Piles being among those diseases which it is sometimes dangerous to cure, care should be taken to distinguish those which ought from those which ought not to be removed. M. Montegre justly remarks that those which are of a constitutional nature, or which the con- stitution, as it were, requires, are generally of long standing—sometimes from youth ; or they replace some serious or habitual affection; they are hereditary, attended by well-marked indi- cations of plethora ; take place from various and opposite exciting causes, or without any obvious cause ; are preceded by constitutional symptoms ; are succeeded by an improved state of health, whether there be discharge or not; and, finally, are accompanied or followed by inconvenience when interrupted or suppressed : all these circumstances indicating a constitu- tional disorder which it is dangerous to meddle with too rashly. When haemorrhoids are more strictly accidental, the symptoms and occa- sions of their appearance are different from the above, and they may be subjected to more active treatment. But even these become, after frequent repetition or long continuance, habitual to the system—often a safety-valve to the circulation, and require a constitutional and cautious treatment. In most circumstan- ces, however, of the disease, strict attention to diet, and to the state of the excretions, with stomachic or deobstruent laxatives, when there is any tendency to constipation ; and with cool- ing diaphoretics when there is any febrile move- ment present, will be productive of benefit. When the secretions and excretions from the bowels are deficient, a few grains of blue pill, or of hydrargyrum cum creta, with one of ipe- cacuanha, and five or six of extract of taraxa- cum or of soap, should be taken at bedtime, and a draught, with equal parts of the com- pound infusions of gentian and of senna the next morning, or a tea-spoonful of either of the electuaries in the Appendix (F. 82, 89, 98, 790) at night. When constitutional irritation ex- ists, the camphor mixture, and solution of the acetate of ammonia, may be given with sweet spirits of nitre, and the inspissated juice of the sambucus, or the infusion of the tilea Eu- ropea with the carbonate of soda or of pot- ash, with the extract of taraxacum. The ni- trate of potash may also be given with the electuary, or in a diaphoretic or diuretic mix- ture. When the complaint is connected with vascular plethora, the treatment should be based upon this circumstance; and a spare farinaceous diet, an open state of all theemunc- tories, and regular exercise ought to be en- forced. If these be neglected, the suppression of the discharge may be followed by some one of the maladies alluded to above. In other respects, the treatment should be directed ac- cording to the peculiarities and complications of the case, as shown in the sequel; and or- gans evincing a tendency to disorder 'onght to be protected either by allowing the haemorrhoi- dal complaint to proceed, or by increasing it ($ 47) when it is insufficient for this purpose or by establishing other sources of irritation or of evacuation. 34. B. Treatment of the Hamorrhoidal Dischar- ges.—a. While the sanguineous discharge is HaEMORRHOIDS—Treatment. 153 moderate, returns after considerable intervals, and leaves no unpleasant effects, it is only a salutary adjustment of the constitution, at- tended, it is true, with inconvenience, but with more than counterbalancing advantages. When, however, it becomes excessive, it ought imme- diately to be restrained. Its excess should be inferred rather from the effects than from the quantity; for some persons will lose large quan- tities of blood, almost daily, for some time, and yet be otherwise in good health. But when- ever the discharge is followed by pallor, debil- ity, syncope, or convulsions or spasms, it ought to be arrested. Like other hamorrhages (see the art., v 35, 45, et seq.), it may be either ac- tive or passive; and the treatment should be di- rected accordingly. 35. a. In the active form vascular determina- tion should be diverted from the rectum by quie- tude and the horizontal position ; by bleeding from the arm when the pulse admits of it, and by cooling drinks and diaphoretics. If these do not succeed, cupping-glasses, with or with- out scarificators, according to the state of the system, may be applied over the hypochondria, as advised by the ancients, or upon the loins or sacrum. Derivatives, especially sinapisms, the terebinthinate epithem, or blisters, may be placed on these or other parts of the surface, and astringent or cold lotions, or injections may be employed.—/?. In the passive form, the acetate of lead with opium; the preparations of cinchona with the mineral acids, or the sul- phate of quinine in the compound infusion of roses; the tincture of the sesquichloride of iron, and other chalybeates ; the balsams of Peru.or of copaiba, in large or repeated doses, or the terebinthinates, and the oil of turpen- tine, or lime-water, administered either by the mouth or in enemata, are the most efficacious means of arresting the discharge. (See art. Haemorrhage, y 45, et seq.)—y. Plugging the rectum, and the actual cautery, have been rec- ommended in extreme circumstances. If the source of haemorrhage is above the sphincter, a fatal internal discharge may follow from hav- ing recourse to the former of these. It is not practicable to resort to the latter, unless the spot whence the blood issues can be brought into view. 36. b. The colourless mucous discharge (y 19) from the anus, although a frequent attendant upon piles, is not necessarily so, as it may be occasioned by ascarides, &c. If it accompany internal or external tumours, and be independ- ent of inflammation, slightly astringent and detergent injections; the internal use of the balsams, or of the spirits of turpentine, or of the balsams or terebinthinates combined with magnesia ; and an occasional recourse to the stomachic aperient mentioned above (y 33), will generally remove it. When it is connect- ed with inflammatory irritation, the means about to be stated (Y 42) are most appropriate. 37. D. Treatment of the Hamorrhoidal Tu- mours.—a. In all cases the parts should be care- fully examined by the practitioner, since the accounts given by patients themselves are very fallacious. Besides, the particular kind of tu- mour must be ascertained before the means of cure can be appropriately directed. Whether the piles be internal or external, or both, the anus should be washed with cold water after 20 each evacuation ; or with yellow soap and wa- ter, as suggested, in the course of some excel- lent remarks on the treatment of the disease, by Mr. Mayo. If the piles be internal, this should be done before they are returned. If they cannot be returned, or are permanently protruded, or altogether external, whatever may be their form, pressure is one of the best remedies that can be applied to them. After each evacuation, and having thoroughly cleans- ed the parts, a conical pad, or piece of ivory, made to slide along a bandage or handker- chief, should be passed between the nates, and fastened above to a cincture, or belt, worn around the loins, in the form of the T bandage. The pad may be provided with a concentric wire spring, the more internal coils of which rise in a conical form. This is the best exter- nal mode of employing pressure. When the tumours are internal, and protrude at stool, dragging the mucous coat with them, or when they consist chiefly of varicose veins, a short metallic bougie, of an oval form, with a short, slender neck, and a conical base to press upon the anus externally, may be attached to the bandage, carefully introduced into the rectum, and worn occasionally. Pressure will thus be made both above and within the sphincter, as well as without it. When introduced, the part of the bougie which rises above the sphincter being oval, varying in diameter with the pecu- liarities of the case, and being many times as thick as its slender neck grasped by this mus- cle, necessarily, from its shape, retains itself within the rectum, draws up with it the exter- nal tumours and prolapsed portion of the bow- el, and presses its conical base externally against the anus, and upon the tumours or en- larged veins external to the sphincter. This combination of the internal with the external method of making pressure on the anus was in- troduced by Mr. Mackenzie into practice, and is often extremely efficacious in the treatment of haemorrhoids, and of the prolapsus attending them. 38. Before having recourse to either of these, it will often be of service to wash out the rectum immediately after each evacuation, by injecting some cold or tepid water, with or without a few grains of sulphate of zinc dis- solved in it; and, if the parts be painful or ir- ritable, a little cold cream, or of a slightly ano- dyne or astringent ointment, or of any other most appropriate to the circumstances of the case, should be applied to the surface of the bougie, when about to introduce it. At the same time, the bowels ought to be kept gently open by any mild or cooling purgative that will not irritate the rectum. I have found equal parts of the compound infusions of gen- tian and of senna, with the soluble tartar, &c, taken at bedtime, the most beneficial, when the digestive organs were weak; and one or two tea-spoonfuls of either of the following electuaries, or of one of those in the Appendix (F. 82, 98), the most serviceable when pleth- ora or hepatic disorder was present, or even when there was a manifest tendency to them. No. 242. R Potassae Bitart. in Pulv. fj.; Sulphuris praj- cipitat. 3i].-iv.; Confect. Senna; Jij. ; Sirupi Aurantii vel Zingib. q. s. ut fiat Electuarium molle. No. 243. R Potassa Nitratis 311.; Confect. Senna, et Si- rup. Zingibers, &a Jjss.; Succi Spiss. Sambuci Si. M Fiat Electuarium. 154 HaEMORRHOIDS—Treatment. 39. These electuaries may be variously mod- ified, according to circumstances ; and the con- fectio piperis nigri may be substituted for the sirup, or the inspissated juice of the sambu- cus, or a small quantity of it may be taken twice or thrice daily, when there is much re- laxation of parts, or in cold, languid, or leuco- phlegmatic habits. Aperient medicines, in haemorrhoidal cases, should always be taken at bedtime, in such doses as.to operate only once, or, at most, twice in the morning. Subse- quent irritation of the bowels during the day will thus be prevented, especially if the rectum be washed out by a lavement after passing a motion. When it is necessary to have re- course to the short bougie described above (Y 37), it should then be introduced, its passage being facilitated by an anodyne or slightly as- tringent ointment or pomade. 40. b. When the tumours are internal and protrude only at stool, and when they continue, notwithstanding the use of the constitutional treatment advised above, aided by the modes of employing pressure just described, the re- moval of them by an operation may be enter- tained ; but it certainly ought not to be prac- tised, unless it be clearly ascertained that they belong to the first variety (y 9), and never, if they present the varicose character (y 12). Most surgical writers make no distinction between these tumours, and resort either to the liga- ture or to excision to remove them. Mr. Cope- land refers to several instances of dangerous, and even fatal results from having recourse to the ligature ; and yet Dr. J. Johnson, in an able review of the subject, states that he knows "that Mr. Copeland's practice is, and long has been, almost invariably to employ the ligature ;" his success, by means of it, entirely depending upon his drawing the thread as tight as possible, so as completely to destroy the vi- tality of the tumour. This is certainly the only mode in which the ligature ought to be employed, and the one in which it has been generally recommended and practised since the days of Galen; but Mr. Copeland only states the danger of this method in his work, and neither advises it nor points out the mode of performing it! Le Dran considers that, in addition to the pain, the ligature may cause inflammation extending along the rectum to the intestines; and M. Montegre objects to it for the following reasons : 1st. The operation is often difficult, and always very painful. 2d. The tumours sometimes resist the ligature, and, instead of falling off, ulcerate. 3d. As they can only be tied in succession, the irrita- tion produced by the first operation increases the swelling and inflammation of those remain- ing. 4th. The ligature may produce all the ef- fects of strangulation of the gut. Dr. J. John- son thinks that these objections are founded on the inefficient mode of applying the ligature, and that few or none of them are valid, provi- ded the thread is drawn to a proper degree of tightness at the beginning. I believe that even this more efficient mode is not secure from danger ; that, in addition to the evils enu- merated by Montegre (a), inflammation of the haemorrhoidal veins, extending even to the liv- er (b), locked jaw (c), retention of urine, and (d) contraction of the rectum have in some instances resulted. It were to be wished that those who have been most in the habit of re- sorting to it would state more fully than they have done the results, and the circumstances in which they confide chiefly in it. In the var- icose form of the complaint, it is a most dan- gerous mode of treatment. 41. c. Excision of the tumours is preferred by Le Dran, Abernethy, Montegre, Colles, and Calvert; while Sir Astley Cooper and Mr. Howship are favourable to the ligature. Mr. Mayo advises this latter method for all in- ternal piles, his mode of operating being the most judicious that can be followed. Sir E. Home and Sir C. Bell recommend a combina- tion of both methods—the excision of the tu- mour immediately after the application of the ligature. There can be no doubt of the danger of excision, and that it is very liable to be fol- lowed by great haemorrhage, and by peritoneal inflammation, particularly when the tumours are formed by varicose veins. Numerous cases illustrative of the fatal or dangerous results of this practice are adduced by several of the au- thors referred to. When the piles are exter- nal, are covered by skin, and are formed as described when considering the first form of tumour (y 9), excision is preferable. But I be- lieve, from considerable experience, that either operation will be very seldom required if the medical treatment be judiciously conducted. Neither the one nor the other should be resort- ed to without a careful examination of the pathological relations of the case, and of the form, state, and complications of the local af- fections ; nor without a preliminary treatment, consisting of one or two small cuppings over the sacrum, of a regulated state of the bowels, moderate diet, and of abstinence from ferment- ed or spirituous liquors. In nervous and irri- table persons either operation is hazardous, and should not be performed unless in urgent circumstances. Dr. Burne states that he has seen " a person die of sympathetic adynamic fever in four days after the removal of piles by a most accomplished surgeon. The nervous system of this patient was disturbed prior to the operation, the shock of which excited high febrile movement and delirium, soon termina- ting in dissolution." [The removal of haemorrhoidal tumours is not to be thought of, unless they become seriously injurious to the health, and threaten to under- mine the constitution. We find them, when neglected, as has been seen, sometimes result- ing in prolapsus, ulceration of the rectum, fis- tula in ano; and in females, fistula between the rectum and vagina; to swelled testicle; dis- eases of the bladder; constant tenesmus and uneasy sensations in the limbs; frequent and copious loss of blood, and its attendant states of anaemia and sinking; palpitations, lowness of spirits, &c. But notwithstanding these evils, great as they are, the surgeon, in view of the past results of surgical operations for the re- moval of these tumours, will hesitate much be- fore undertaking their cure, either by excision or ligature. We do not allude to those tem- porary evils, such as tenesmus, strangury, gas- tralgia, and nervous symptoms, which so fre- quently follow the operation, but phlebitis, te- tanus, excessive haemorrhage, and fatal collapse from the shock of the operation itself. There are others, also, of a more permanent charac- HaEMORRHOIDS—Treatment. 155 ter, such as contraction or stricture of the anus, extensive abscesses, obstinate fistula, and, finally, a state of general plethora, from suddenly checking the frequent loss of blood in a system long habituated to it, and, conse- quently, to an accelerated process of sanguifica- tion. Dr. John Watson, of New-York, has very forcibly called the attention of the profession to the dangers attending the operations,* both of excision and the application of the ligature for the removal of haemorrhoidal tumours, and states that within eight years he had known of four fatal cases ; one after excision, and three after the application of ligature, but none by haemorrhage. One fatal case has also recently occurred in this city, after the operation by lig- ature. One fatal case occurred in the practice of the late Dr. Physick, of Philadelphia, from phlebitis, on application of the ligature. Two serious cases occurred in the practice of J. L. Petis, where, after the operation of tying, symp- toms occurred similar to those of strangulated hernia—nausea, vomiting, hiccough, and ab- dominal pains : one of these proved fatal. The late Dr. Bushe was of opinion that phlebitis was not one of the accidents likely to occur after these operations. " Haemorrhoidal tu- mours," says Dr. Watson (loc. cit.), " are either external or internal. The first are readily managed, either by incision, excision, ligature, or caustic applications. The internal, however, are worthy of much more serious consideration. They rarely extend above the pouch of the rectum, and are, therefore, generally within reach. Hence the great success of operations upon them when properly performed, and where the patient escapes the first effects of the op- eration itself. But, in some cases, I have known them situated so high up within the rec- tum as to be beyond the reach of either knife or ligature. Tumours of this sort may, in the end, give rise to prolapsus of the mucous mem- brane, descend with the descending prolapsus, and finally come within the surgeon's reach. So long, however, as they remain high up, be- yond the verge of the anus, although they may frequently bleed, or harass the patient and un- dermine his health, they are not to be inter- fered with, except by enemata, suppositories, and the administration of internal remedies. " For these bleeding internal haemorrhoids, I have found more benefit in the use of injections of acetate of lead than in any other form of local application. I commonly employ this of the strength of a drachm to eight ounces of rain water, and never administer over two ounces of this solution at a time. I repeat the injection after each return of haemorrhage ; and, as this most commonly occurs during the effort to evacuate the bowels, I commonly ad- vise the patient to resort to the injection imme- diately after every stool, until the haemorrhage has ceased for a few days. The usual internal medicines are, the occasional administration of a blue pill, especially where there is reason to suspect any disturbance in the functions of the liver ; a dose of oil, or the extract of taraxacum, or some other mild laxative. But, for the mere evacuation of the bowels, and with the view of correcting an obstinately-constipated habit, I * (The New-York Journal of Medicine and Surgery and the Collateral Sciences, vol. iii., N. Y., 1844.] know of no article better than one or the other of the following confections : First. Common Rosin, well pulverized, ?i.; Clarified Honey, ?v. M. Second. Common Rosin, as before, ?i. ; Balsam of Copaiva, ?ss.; Clarified Honey. sivss. M. " The last of these, when it can be borne, is the most efficacious. But to many persons, and particularly delicate females, the balsam is so nauseous that they are unable to use it. The ordinary dose is from two to three drachms at bedtime. This dose is generally sufficient to produce one soft and consistent stool early on the following morning, without griping, unea- siness, or any of the usually disagreeable at- tendants of cathartic medicine. These meas- ures are to be assisted by the occasional use of the hip bath ; by cooling, anodyne, and emoll- ient clysters; by a course of regimen most suitable to keep the bowels regular, without, however, stimulating them ; and, above all, by carefully and gently reducing the prolapsus after every evacuation of the bowels, and guard- ing against all movements likely to produce it in the intervals.'"* The late Dr. Physick, who was very success- ful in the treatment of piles, resorted to their excision by scissors, when external and cov- ered by skin; and to the wire ligature, when internal and enveloped with mucous membrane, in order to avoid danger from haemorrhage, which he believed was considerable. Dr. Har- ris, however, of Philadelphia, who has also had much experience in the treatment of the dis- ease, always practises excision, and states that, in his numerous operations, he has never encountered any of the accidents alleged to have followed this plan. Dr. Chapman strenu- ously opposes the ligature as a most dangerous and painful mode of treatment, and recom- mends excision, excepting in the varicose tu- mour. (Lecture on Hamorrhages, &c, Phil., 1844.) Dr. Houston, of Dublin, has lately called the attention of the profession to the use of nitric acid in haemorrhoidal affections. (See Braith- waite's Retrospect, part vii., art. 62; part x., art. 64.) He confines its use to the internal bleeding piles—that soft, red, strawberry-like elevation of the mucous membrane, called by some vascular tumour, which it removes by producing a slough on its surface. The part to be touched must be free from cuticle, and wiped dry, or freed from all mucous or other adherent fluids. The acid is to be applied free- ly, and rubbed in with force enough to be press- ed into the pores of the surface. A slough fol- lows ; but often a second, or even a third appli- cation may be required before the disease is cured, especially where the tumours are old or firm in texture. Dr. Watson remarks that this remedy may prove useful when the disease lies near the surface of the mucous membrane, or is entirely confined to it; but that he should expect little benefit from it where the haemor- rhoidal tumours lie deep, and are enveloped in thickened and indurated mucous membrane and cellular tissue ; where the mucous coat of * (The reader may profitably consult, in relation \o the surgical part of the treatment of these tumours. Dr. Wat- son's paper in the New-York Jour, for July, 1844. and Dr. Bushe's Treatise on the Malformations, Injuries, and Dis- eases of the Rectum and Anus, New-York, 1837, 8vo.J 15G HaEMORRHOIDS—Treatment. the rectum is varicose and tumefied, the solid nitrate of silver may be often used with advan- tage ; but it must be employed very freely, and every day or two, for weeks together, in order to effect a permanent cure. Where we conclude to apply the nitric acid, it may be done in the following manner: the patient is directed to strain, so as to bring the tumours fully into view ; and while they are so down, let him either lean over the back of a chair or lie on the edge of a bed, on the side on which the disease exists. A piece of wood made into the shape of a spatula should then be dipped in the acid, and as much of it applied as will adhere to it, rubbing it on as above di- rected. When the membrane is changed to a grayish white colour, smear it with oil, and gently replace the prolapsed parts within the sphincter ; put the patient to bed, and adminis- ter an opiate. The pain, which is often sharp and burning at first, soon subsides, and does not again return in the same form.] 42. E. Treatment of Inflamed Piles.—The ap- plication cf leeches to inflamed haemorrhoids is very often advised. Montegre disapproves of the practice, as it frequently draws the blood to the parts. I believe that cupping on the loins or on the perinaeum is more beneficial. As more or less strangulation produces or accompanies the inflammation, the tumours should be pushed within the sphincter, if this can be done without aggravating the affection ; and poultices or fomentations applied. When the inflammation is abated, Montegre advises injections of cold water; but care should be taken not to lacerate the tumours by the pipe of the syringe, as serious consequences may accrue, as in the cases recorded by Zacutus Lusitanus, Gassendi, and others. The exter- nal application of lint, moistened with a cooling and anodyne lotion, or frequently sponging the parts with it, will often afford relief. Equal parts of the solution of the acetate of lead, and of laudanum, diluted with rose water, will gen- erally answer the purpose. If this lotion is not of service, it may be relinquished for poultices or poppy fomentations. Incisions or punctures of the inflamed and protruded piles are advised by some surgeons. Montegre condemns the practice; and Mr. Calvert stales that he saw an instance of fatal haemorrhage from having had recourse to it. Much more dependance should be, therefore, placed upon local blood- lettings in the situations just mentioned, on low diet or abstinence, and on the refrigerants and cooling diaphoretics already recommended. If the inflammation terminate in suppuration or abscess, poultices or fomentations, and as early an external outlet to the matter as can be given it, are requisite. When tenesmus is present, cupping over the sacrum, ipecacuanha, with nitrate of potash and opium, in frequent doses, anodyne fomentations, and the treat- ment about to be prescribed for this symptom (y 46), are most serviceable. The bowels should be kept gently open by means of castor oil, the aperient electuaries, and other laxatives mentioned hereafter (y 46, c). 43. F. Treatment of Ulcerations, Fissures, or Cracks.—a. When ulcerations form between the tumours, or on their surfaces, the parts should be carefully cleansed after each evacuation, and an ointment, with a small proportion of Peru- vian balsam, may be applied to it by a pledget of lint, or any other ointment of an astringent and anodyne kind may be tried. The balsams or terebinthinates should be given internally, in the form of pill, with magnesia, in quantity sufficient to keep the bowels gently open. 44. b. Fissures or cracks between the tu- mours are attended either by exquisite pain, or by spasmodic constriction of the sphincter. More frequently both these latter morbid states are present, and occasionally the patient is tolerably free from both. When the lesion is thus simple, the treatment recommended for ulceration will often be sufficient; the local application of biborate of soda, dissolved in honey, will also be of service as a substitute for an ointment; but when either pain or spasm of the sphincter is complained of, other means are required. In these cases, I have found the addition of the extract of belladonna to any of the ointments usually prescribed, give almost immediate relief. If a large proportion of the extract be employed, the effects ought to be carefully watched. Due attention to the func- tions of digestion and of excretion, and to existing constitutional symptoms, is always necessary. In less severe cases of this de- scription, the extract of hyoscyamus may be tried before having recourse to the belladonna. M. Boyer and most surgeons in this country have advised a complete division of the sphinc- ter ani muscle for the removal of this com- plaint. I have treated five cases of fissured anus since 1822, when the first came under my care. In all these the operation had been rec- ommended ; and yet they perfectly recovered in a short time, and, without a single exception, by means of a purely medical treatment. Strict injunctions as to diet and regimen ; the daily evacuation of the bowels, and afterward wash- ing out the rectum by emollient injections; careful ablution of the external parts, and the application of an appropriate ointment or cerate with belladonna ; attention to the functions of the digestive and assimilating organs, and to constitutional symptoms, and the removal of general or local plethora, constituted the treat- ment. The belladonna was added to various kinds of ointment, according to the peculiari- ties of the case. In all it affected the pupils, and in two it produced its characteristic erup- tion on the skin. Several years after I first employed this medicine for fissure, with painful spasm of the sphincter, the account of M. Du- puytren's treatment of this affection by the same means appeared in the medical journals of Paris. [In the treatment of this extremely painful affection, the patient should maintain the re- cumbent position, and confined to a low diet. Cathartics are to be carefully avoided, and irri- tation allayed by simple enemata of flax-seed tea. When the disease is mild, we have found the application of the unguentum acetatis plumbi prove sufficient for its healing ; and if there be much spasm of the sphincter, the extract of belladonna will prove a powerful auxiliary: a drachm of this substance, with the same quan- tity of the acetate of lead, mixed with six drachms of lard, is the preparation of Dupuv- tren, which has been so extensively used in these cases. A very good practice is, to apply the nitrate of silver to these fissures when HAEMORRHOIDS—Treatment. 157 superficial, and then introduce meshes of lint, besmeared with a mass consisting of one part of the extract of belladonna, and seven of sper- maceti ointment—a course of practice which has succeeded in cases where Dupuytren's ointment has failed. The late Dr. Bushe, of this city, was in the habit, where other means failed, of dividing the stricture with the knife, a procedure, he states, "which never fails to give immediate relief, and to effect a rapid cure."*—(Loc. cit.). This practice, however, originated with Boy- er, who regarded the fissures as the conse- quence of a spasmodic contraction of the sphincter ani. This, however, as M. Jobert has pointed out (Gaz. Med. de Paris), is more than questionable. The spasmodic contraction of the sphincter seems to be rather the effect than the cause of the ulcerated fissure of its mucous covering and of its surface. It is the irritation to which its superficial fibres are ex- posed that induces the spasmodic contraction of the muscles. It is of importance to attend to this circumstance, viz., whether the ulcera- tion is limited to the mucous lining of the gut, or whether it has extended to the fibres of the sphincter ani, in the management of the dis- ease. In the former case, it is rarely necessa- ry to have recourse to the scalpel; the ulcer- ated fissure will generally heal under the use of caustics, &c. But when once the fibres of the sphincter are involved, and the consequent spasmodic contractions of the muscles is in- duced, the application of any irritating sub- stance tends only to aggravate the suffering; and some suppose the only successful mode of treatment is probably to divide the muscles across. M. Jobert has, however, found that simple excision of the diseased part, with the knife or scissors, will relieve the spasmodic contraction of the sphincter, by bringing the fissure to the state of a simple wound, and thus cure the disease.—(Loc. cit.)] 45. G. Hamorrhoidal Pains and Spasmodic Stricture of the Rectum, generally connected with fissure or ulceration at the bases of the tumours, must be treated in the manner just stated (y 44). The pains are often intermit- tent, but very acute during their continuance. Sometimes they extend down to the feet and ankles, and even occasionally assume a neu- * [In performing the operation, Dr. B. recommended that the patient should be placed opposite a window, on his side, an assistant being employed to separate the buttocks, and retain them so during the operation. The surgeon is then to insert the forefinger of the left hand, well oiled, mto the anus, as far as the second joint, which is to serve as a conductor for the knife, which should have a blade two inches long and one eighth broad, with a blunt extrem- ity. Having passed the blade flatwise as high as the supe- rior border of the internal sphincter, he then turns its edge towards the fissure, provided it be on the side of the bowel, and divides both sphincters by cutting outward, gradually increasing the pressure so as to ensure the complete section of the external muscle. If a fissure exists on the opposite side, Dr. B. recommends to treat it in the same manner. If the seat of disease be the anterior or posterior portions of the intestine, the incision is to be made on the side, as the division of the sphincter, and not the fissure, is the ob- ject in view. After the haemorrhage ceases, dossils of lint should he placed in each wound, and secured by a compress and T bandage. A full dose of morphine is to be given, and nothing but toast-water, broths, and gruel allowed for two or three days. The dossils of lint, compress, and ban- dage are then to be removed with gTeat care, the bowels evacuated with an emollient lavement, and fresh dressings applied. This course is to be pursued daily, gradually di- minishing the size of the dossils of lint, until the wounds heal, which will be iu about three weeks.—(Loc. cit.)] ralgic character in these or other parts of the lower extremities, or give rise to spasm in various parts, especially in nervous or hyster- ical females. Some interesting instances of such affections have been recorded by Sir B. C. Brodie, and have been observed by myself. In such cases, much benefit will generally ac- crue from taking the confectio piperis nigri twice or thrice daily, and from adopting the constitutional and local treatment just recom- mended. This medicine may also be conjoined with an anodyne, and the bowels regulated by the medicines already suggested. M. Monte- gre strongly advises having recourse to the " douche ascendante ;" or the forcible dashing of cold water against the anus, and to cold injec- tions. In order to render the evacuation more easy, he directs the lavement to be thrown up when the inclination to stool takes place. Emollient injections may also be tried, either to facilitate the discharge, or to cleanse the rectum afterward ; and suppositories with the ceratum plumbi compositum, and opium, or stramonium or belladonna, or any other nar- cotic, may be occasionally introduced into the rectum, and they will seldom fail of giving re- lief. Great care ought to be taken in the ad- ministration of narcotics in lavements, in the treatment of this or any other state of the com- plaint, as they are often rapidly absorbed into the circulation from the rectum and colon, and without having undergone any change. I have known half a grain of the belladonna in one case, and thirty drops of laudanum in another, produce the most serious effects. When, how- ever, either of these, or any other narcotic, is prescribed in an ointment, pomade, or supposi- tory, no unpleasant results will follow. 46. H. Tenesmus, Strangury, and Constipa- tion, often depend upon the same pathological states.—a. The tenesmus is generally owing to inflammatory irritation and congestion of the inner coats of the rectum, conjoined with spas- modic action of the muscular tunic. It will, with few exceptions, be removed by the means just directed (y 42, 45). In less acute, or more obstinate cases, the belladonna plaster may be applied to the perinaeum or sacrum. Five or six grains of the extract of poppies, or one or two drachms of the sirup, may also be occa- sionally thrown into the rectum, with any tepid emollient enema ; or a suppository of the kind just stated may sometimes be introduced.—b. If strangury or dysuria supervene, it is to be imputed to the extension of the affection of the rectum to the neck of the bladder, or to the prostate and urethra ; and it will generally be found that it will be removed or relieved by the treatment recommended for tenesmus.—c. Con- stipation also frequently proceeds from the same local changes as occasion tenesmus and stran- gury, and from tumouTS or enlarged and con- gested vessels obstructing the canal of the in- testine. In either case, there is more or less obstacle to the passage of a consistent motion, and much pain attending it. If these symp- toms be allowed to continue, the complaint will be aggravated ; or they will give rise to still more serious changes. In removing them, the milder laxatives will be found more serviceable than active purgatives; but those which act also upon the liver should be selected. Mer- curials aggravate, and even bring on tenesmus, 158 HAEMORRHOIDS—Bibliography and References. and therefore cannot be employed, with the exception of hydrargyrum cum creta. This may be taken in small doses at bedtime, with ipecacuanha and hyoscyamus, or with extract of taraxacum. Some one of the electuaries already prescribed (y 38), or the decoction of taraxacum with the carbonate of soda, or the tartrate of potash with tincture of senna and sirup of roses, or of senna, may be given and continued for some time. A Seidlitz powder, taken about an hour before breakfast, is also one of the best aperients in haemorrhoidal cases. A frequent recourse to warm lave- ments is injurious in this complaint, as they relax the parts and solicit the circulation to them. M. Montegre, whose authority in this matter is very high, advises the injection of cold water in preference, as it strengthens the bowel; but he directs no more than will fill the rectum (about half a pint) to be thrown up. In the more severe states of the disease, especial- ly in cases of fissure, of spasm of the sphincter, and of painful evacuation, he considers the cold injection, every time that a motion is about to be passed, most beneficial. 47. /. Re-establishment of Suppressed Hamor- rhoids.—When the suppression or interruption of piles is followed by aggravation of some re- lated complaint, or injures the general health, or threatens some important organ, as the lungs, brain, liver, &c, there ought to be no hesitation as to having recourse to means cal- culated to reproduce them. A gentleman of about fifty, residing near Russell Square, sub- ject to returns of humoral asthma often pass- ing into bronchitis, as well as to frequent at- tacks of haemorrhoids, experienced great aggra- vation of the former in 1835, after the latter had disappeared for some time. I directed him to be cupped, but he neglected to adopt my ad- vice ; I therefore prescribed a full dose of cal- omel and aloes, and repeated it in a few hours, with the view of restoring the suppressed piles. This had the desired effect; but severe inflam- mation of the tumours and strangury superve- ned, followed by an abscess between the pros- tate and anus. This broke externally, and soon healed, and the patient has not been confined a day since. Another gentleman, between fifty and sixty, had experienced severe headaches from the non-appearance of the haemorrhoidal discharge. He was advised in 1829, when I saw him, to lose blood, to live abstemiously, and to relinquish malt liquors. The first only of these injunctions was complied with, and his complaints returned. The same advice was again given, and the purgatives formerly prescribed were changed to those which act most energetically on the rectum. The haem- orrhoids were reproduced, and the headaches disappeared. Such instances are, however, not at all uncommon. Unless in urgent ca- ses, it will be preferable to attempt the resto- ration of piles by the more gentle means at first, as the exhibition of those which are most irritating, before the action of milder remedies is ascertained, may excite inflammatory action of a very severe kind, and great distress, as in the case first adduced. A reference to the causes which commonly occasion the complaint will show the means most likely to reproduce it. The most appropriate, however, are. pedi- luvia or semicupia ; the hip-bath; the applica- tion of leeches to the anus ; the use of purga- tives which act especially on the rectum, as calomel and other mercurials in full doses ; al- oes, colocynth, rhubarb, sulphate of soda, &c. ; warm injections ; aloetic enemata, &.c. 48. K. Of Regimen and Prophylaxis.—An ab- stemious regimen is required during the attack, and is even more necessary in the intervals; for it is chiefly by diet and prudent conduct, at these times that this complaint and its contin- gent ills are to be warded off. A temperate climate is best suited to persons liable to haem- orrhoids ; but sudden vicissitudes of weather are unfavourable, and should be guarded against by wearing flannel next the skin, and by warm clothing. Malt and spirituous liquors ought to be avoided, and temperance in food and drink should be observed. Too warm and soft beds are improper ; and sitting on soft, warm cush- ions is still more so. Regularity in the hours of eating, sleeping, waking, and taking exer- cise is generally of service ; and when medi- cine is requisite, it should be such as will cor- rect morbid action, increase scanty secretion and excretion, particularly of the biliary and mucous surfaces, and preserve the bowels reg- ularly and gently open. Cold ablution of the anus after each motion, and, if haemorrhoidal tumours protrude, the careful sponging of them before they are returned, will not only remove disorder, but prevent its return, if continued without interruption in winter as well as in summer. Venereal excesses, the more violent mental emotions, and all the depressing pas- sions, are injurious. Exercise in the open air, especially on horseback, is always of service if taken regularly, although rough riding, espe- cially by those who are not accustomed to it, is often a cause of the complaint. (See, also, Rectum—Diseases of.) Bibliog. and Refer.—Hippocrates, Tlcpt Aluopfiotiov, Opp., p. 891, ed. Foes.—Celsus, L., vii., cap. 30.—Galen, De Comp. Med., loc. ix., cap. 7.—Scribonius Largus, De Comp. Medicam, c. 91.—Paulus Mgineta, 1. vi.,c. 79.—Ac- tius, Tetr. iii., serm. i., c. 46.—Oribasius, Synopsis, 1. ix., cap. 18, 42.—Avicenna, Canon., 1. iii., fen. x., tr. i., cap. 2. — H. Barlandus, Epist. de Aquarum destil. facultat. et Haemorrh. Generibus, 8vo. Antwerp, 1536. — Ballonius, Consil., t. ii., p. 51 ; t. iii., p. 98.—Rhodius, Cent, ii., obs. 93.— Glisson, De Ventriculo et Intestinis, tr. ii.. c. 11.— Amatus Lusitanus, Cent, vi., cur. 32.— Riedlin, Millenari- us, n. 401, n. 517, n. 742, n. 996.—/. C. Fromman, De Haemorrhoidibus, 12mo. Noriberg, 1677.—Zacutus Lusita- nus, Med. Pr. Hist., 1. ii., obs. 26.—Lentin, Obs. Med., fascic. ii., p. 68.— Bonet, Sepulchr., 1. iii., sect, iii., obs. 87. —G. Baglivi, Opera omnia, 4to. Ley den, 1745, p. 826.— /. A. Gulich, Meditationes Theoret. Pract.de Furore Haem- or. Internarum. Lugd. Bat., Svo, 1733.—Pelargus, Med. Jahrg., iii., p. 734; iv., p. 302.—F. Hoffmann, De Salu- britate Fluxus Haemorrhoidalis. Hal., 1708 ; et De Immod. Haemor. Fluxione. Halae, 1730.— Peschel, Epist.de Hem- orrhoidum Laude circumcidenda. Leips , 1713.—fohreni- us, Diss, de Philistaiorum Hlaua, 4to. Franc, 1715.—Gar- mann, Caut. Pract. circa Cur. Flux. Hiemor. Bas., 1715.— D. M. Albertus, Tract, de Husmorrhoidibus, 4to. Hahe, 1722; De Haemorrh. et Mensium Concensu. Hala, 171JI; De Hamorrh. Sympt. et Pernic, 1726 ; De Diff. Haemorrh. ab alns Crueutis Alvi Fluxibua., 1727; De Ham. Fremina- rum, 1717 ; De Haem. Suppressis. Halse, 1718 ; De H«m- or. Gravid, et Puerp.. 1727 ; et De Ha-m. luniorura, 1727 ; et De Haemor. Pra-servatione, 1727.—G. E. Stahl, Abhand- lung von der Goldenen Ader, 8vo. Leips., 1729; De Hasm- orrh. Motus et Fluxuum Haemorrhoidum Diversitate. Of- fenb., 1731; et De Dubia et Suspecta Hiemor. Laude. Hahe, 1,33.—F. Hoffmann, Diss, de Cephahea cum Hicm- orrhoidali Fluxu. Hal., 1735 ; et Consult., cent, ii., n. 25, etseq.—J.A. Gulich, Med.de Furore Haemorrhoidum In- ternarum, 8vo. Lugd. Bat., 1733.—Juncker, De Prolapsu Intest. Recti pro Tuherculis Hiemorrh. perperam habito. Hals, 1740; De Tenesmo Haemorrhoidali. Halao, 1744.—, Richter. Censura nimiae laudis Haemorrhoidum. Gofit., 1744.—Morgagni, Epist. xxxii., passim.—Perotti, in Rac- colta d'Opuscoh Scientifici, Ac, xvi., p. iib.—Flajani, Col- HAIR—ALTERATIONS OF—Pathology. 159 lez. d'Osservazioni, t. ii.,n. 45.—Chomel and Morand, Ergo Tumidis Hwmorrhoidibus Hirudines. Paris, 1750.—F. A. Kreutzer, Ob die Goldeiie Ader Zutrllglich sey ? 4to. Ko- nigsb., 1751.—A. De Haen, Theses Pathologies de Haem- orrhoidibus, 8vo. Vindob., 1759.—E. J. Neifeld, Physica- lischo Abhandlung von der Goldenen Ader, 8vo. Tull., 1761.—C. T. E. Reinhard, Abhandlung von dem Mastdarm- blutfluss, 8vo. Glog., 1764.— Triller, De Haemor. Fluxu nunc Salutari nunc Noxio. Witeb., 1764.—/. Quarin, An- iinadvers. Pract., cap. xiii., p. 257. — A. Schaarschmidt, Nachricht der Krankheiten die auf die Goldene Ader, &c, 8vo. Berl., 1771.—Rosenblad, De l.aude Haemor. Restrin- gend. Lund., 1771 ; et De Haemor. Provocandis. Lund., 1777.— Buchhave, in Act. Soc Med. Haun., t. ii . p. 403.— Stunxer, Ueber die Goldeiie Ader. Wien., 1783.—Moeh- ring, Observ. 23. —Michaelis, in Richter, Chir. Bibl., b. vii., p. 583.— Adair, Med. Facts and Observations, vol. iv., n. 3. — M. Stoll, Rat. Med., vol. iv., p. ilS.—Bang, Act. Reg. Soc. Med. Havn., vol. i., p. 18; vol. iv., p. 142.—Callisen, Ibid., vol. ii., p. 331.—Banyer, Philos. Trans., vol. xiii., n. 2.—llierling, Advers. Curios., ohs. 21.—Chalmers, On the Weather and Dis. of South Carolina, vol. i., p. 100.—Lo- effler, Beyttage, b. i.—J. C. Stuntzer, Ueber die Goldene Ader, 8vo. Wien , 1788.—/. B. Reitler, De Haemorrhoidi- bus, 8vo. Vien., 1789.—N. R. Molitor, Abhandlung ueber die Hiemorrh., 8vo. Leipz , 1790.— K. A. Bitzius, Ursachen und Bchandlungsart der Haemorrh., 8vo. Hamb., 1794.— W. De Kr. Trnka, Hist. H*m., 8vo. 3 t. Wien., 1794-95. —G. Hildebrandt, Ueber die blinden Haemorrhoiden. 8vo. Erl., 1795.—/. Ware, Remarks on Fistula Lachrymalis and Haemorrhoids, 8vo. Lond., 1798.—/. G. Knebel, Abhand- lung ueber die Haemorrhoidal Krankheit. &c, 8vo. Brest., 1799. —/. C. A. Recamier, Essai sur les Haemnrrhoides, 8vo. Paris, 1800.— W. Cullen, Works, by /. Thomson, vol. i., p. 285; vol. ii., p. 213, 267,270, 273.—Schmucker, Vermischte Schriften, b. i., p. 87.—G. W. Becker, Die Haemorrhoiden. Weissenf., 8vo, 1804.—/. W. H Conradi, Von den Hasm- orrhoiden. Marb., 8vo, 1804.—Petit, CEuvres Posthumes, t. ii., p. 155.—Schmucker, in Richter's Chirurg. Bibliothek., b. v., p. 231.—Monteggia, Institut. Chirurgiche, Parte ter- za. Milan, 1805, p. 521.—Vogel, in Salzburger Chir. Med. Zeitung, 1791, ii., p. 235.—Michaelis, Hufeland's Journ. der Pr. Heilkunde, b. xii., 4 st., p. 50.—Joerdens, in Hufe- land's Journ. der Pract. Arzneyk., b. iv., p. 228.—Henning, in Hufeland's Journ. der Pract. Heilk., b. x., st. 2, p. 158. —Hufeland, in Ibid., b. ix., st. 3, p. 106.—Horn, N. Archiv., b. i., p. 123, 277 ; et Beytrage zur Med. Klinik., b. ii., p. 432.—B. De Larroque, Traite des Hemorrhoides. Paris, 1812.—F. A. May, Die Haemorrhoiden, 8vo. Mannh., 1802. —G. W. Becker, Die Haemorrhoiden, 8vo. Weis., 1804.— /. W. H. Conradi, Von die Haemorrhoiden, Svo. Marb., 1804.—/. Earle, Observ. on Haemorrhoidal Excrescences, 8vo. Loud., 1807.—A. Portal, Me moires sur la Nature et le Traitement de plusieurs Maladies, t. v.—J. F. C. A I- brecht, Die Haemorrhoiden, ihre Behandlung, Ac, 8vo. Hamb., 1809.—PA. Pinel, Nosograph. Philosophique, t. iii., p. 456.—D. G. A. Richter, Die specielle Therapie, b. iii., p. 344.—L. J. Schmidtmann, Summa Obs. Med., vol. iv.. p. 41(1.—/. Kirby, Observations on the Treatment of Haemor- rhoidal Excrescences, Svo. Lond., 1817. — J. Abernethy, Surgical Works, vol. ii., p. 234.—A. J. De Montegre, Diet. des Sc. Med., art. Hemorrhoides, t. xx. Paris, 1817; et Des Hemorrhoides, Traite: analytique, tc, a serpent); Ophiasis, Celsus ; Area, Auct. var. ; Alopecia Areata, Sauvages ; Porrigo decalvans, Willan, Bateman ; Tricho- sis Area, Good ; Alopecia partialis, Alopecia circumscripta. 23. Charact.—Bald patches, often without de- cay or change of colour of the surrounding hair, the bared spots being often shining and white, fre- quently spreading or coalescing. 24. Partial alopecia is the consequence of various alterations of the secreting follicles of the hair, induced by impetigo, fevers, chronic eczema, sycosis, &c. The variety described by Willan, under the name of Porrigo decal- vans, is the most remarkable which comes un- der the present head. The scalp, or skin of the chin or cheeks of persons affected with it, presents one or more patches, frequently of a circular form, entirely devoid of hair, although surrounded by that of the natural growth. The skin of these patches is smooth, without red- ness, and often unusually white; and their areas extend gradually. When several exist near each other, they ultimately unite. A large portion of the scalp may be thus denuded of hair. Neither vesicles nor pustules, nor any other kind of eruption, can be detected in the surface of these patches. This affection oc- curs commonly in the hairy scalp, and in chil- dren ; but it is not infrequent in adults, and in the beard. In children it often assumes an ir- regular serpentine or winding form. I have seen it in them associated with various disor- ders of the digestive organs, and occasionally with those of the brain; but it has also been apparently independent of any internal affec- tion. Dr. Elliotson has seen it in a child with disease of the brain (Lond. Med. Gaz., vol. vii., p. 639, and vol. viii., p. 30). The ca- ses which I have met with in adults were not connected with any other disorder. I agree with Good, Rayer, and Todd in viewing it as a variety of alopecia, and entirely unconnected with porrigo. 25. A variety of partial alopecia has been no- ticed by MM. Mahon, Rayer, and myself, that differs from the preceding chiefly in the appear- ance of the affected surface, and in the pres- ence of a few altered and brittle hairs. In this latter respect it nearly approaches the morbid state of the hair already mentioned (y 10). On one or more circular patches, the hair seems broken off to within a line or two of the skin. The surface of the patches is dry, appears rough to the eye, and feels more so to the touch. It is slightly bluish, and a fine, white powder can be detached from it. The affec- tion begins at a point, and spreads, similar spots forming in the vicinity of the one which first appeared. These may extend until nearly all the scalp becomes affected. ii. Diffused Alopecia.—Syn. Cahities, Depi- latio, Defluvium PUorum, Auct. var. ; Tricho- sis Atherix, Good. 26. Charact— The decay or fall of the hair oc- curring in a diffused or general manner; the hair HAIR—Los s of—Cau ses—History—Pathology. 163 becoming gradually thinner, commonly, at first, on the crown, or on the forehead and temples. 27. Decay of the hair in a gradual and diffu- sed manner may take place prematurely, and as a consequence of disorder of the digestive organs, or of the constitution, or of a local af- fection of the scalp extending to the pilous fol- licles. It is often an indication of premature exhaustion of organic nervous energy. Con- genital absence, or defective development of the hair of a permanent kind (y 21), has been rare- ly observed. Instances of it have been record- ed by Heister, Dans, Wells, and Rayer. Premature loss of hair is not confined to the scalp, but often extends to the eyebrows, beard, and other parts of the body. It may be even general. Mr. South (Translation of Otto's Pathology, p. 120) mentions a case most prob- ably of this kind. A total loss of hair, howev- er, is more common than general defective de- velopment of a permanent kind, and is met with chiefly in mature or far advanced age. J. P. Frank saw it in a young man ; and instan- ces of its sudden occurrence are recorded by Paulini and Heister, and in the Journal de Physique (t. xiv.), and in the Berlin Medical Transactions (t. iii., p. 372). Most commonly, the hair of the head, of the axillae, and pubes gradually and successively fall off. In rare in- stances, the hair has been renewed of a finer quality, as in the cases recorded by Lemery and Bonina (Journ. des Progres, &C, t. xiv., p. 244). A singular case of baldness, confined to one side of the body, is related by Ravaton. 28. Causes.—A. The remote causes of baldness are, whatever debilitates and exhausts the system, as profuse or prolonged discharges; dangerous haemorrhages ; masturbation, or im- moderate indulgence of the venereal appetite ; low, typhoid, or adynamic fevers ; care and dis- appointments ; the depressing passions and anxiety of mind; excessive application to study; the contact of rancid, septic, or putrid animal matters with the scalp ; more rarely the syphilitic poison, and the frequent or prolonged use of mercury. It may also be caused by ex- posure to the sun's rays; by the fumes of quicksilver, by the friction of a military cap or helmet; by eczema or other chronic eruptions of the scalp, and by the use of tobacco. It has been said to be endemic in some places. Leo Africanus has stated that baldness is common in Barbary ; Tournefort, that it is almost universal in Mycone, one of the Cyclades; and Sir R. Sibbald, that it was frequent in Shet- land in his time, owing to the fish diet of the inhabitants. That living chiefly on fish, and on poor, unwholesome food may aid in its produc- tion, is not improbable. The salts of sea-wa- ter left in the hair will sometimes cause it in- directly. Extreme distress of mind has pro- duced a general loss of hair within twenty-four hours ; but such instances are extremely rare. Since Hippocrates, it has been said that eu- nuchs do not become bald ; and Schenck re- marks that baldness does not commence until after the generative functions are exercised. It is certainly much less frequent in females than in males. 29. History and Pathology.—A. The fall of the hair may take place in a few days, or even in a shorter period ; or so slowly as to escape observation. The skin of the denuded part usually presents the ordinary appearance, especially in senile alopecia. In some cases it is pale, or of a dead, whitish colour, and furfura- ceous; and occasionally it is covered by scurf, or scales, and is distinctly inflamed. In the former case, its sensibility is not materially al- tered ; in the latter, there is heat, itching, or pricking. The hair is often more or less al- tered before it falls out, being thin, harsh, dry, weak, and stunted, or deprived of colour. This is most frequently the case when it proceeds from causes acting directly on the scalp, and from chronic eruptions of this part. 30. B. Loss of the hair proceeds from chan- ges in the bulbs, 1st. From atrophy or wasting of the follicles, as in senile alopecia, and in that state of the affection which is produced by ex- cessive venereal indulgences; 2d. From an impaired or suspended vital action of the pilous follicles, as in the alopecia that takes place sud- denly or rapidly from mental emotions, &c.; in that which follows malignant adynamic or putrid fevers; and in that variety which has generally been known by the name of porrigo decalvans; and, 3d. From chronic inflammation, extending to the bulbs. Equally important with a knowledge of the particular condition of the follicles of bulbs to which the loss of hair is to be imputed is the investigation of the af- fections with which it is related, or upon which it is dependant. Although alopecia is often a strictly local and primary affection, proceeding directly from local causes ; yet it as frequently depends upon disorder of the digestive and as- similating organs, and upon the general state of the system. As Dr. T. J. Todd justly re- marks, it may arise not only from a change primarily induced in the follicles, but also from the extension of disease to them from the tis- sues in which they are situate. In this latter case, the alopecia may be also local, but it is consecutive, the follicles being altered by becom- ing involved in the inflammation constituting an adjacent cutaneous disease. The baldness following eczema, porrigo, impetigo, &c, is an illustration of this. 31. C. Alopecia is most frequently sympto- matic of debility or cachexia, produced by the exhausting causes enumerated above (y 28). Af- ter fevers, the hair is generally exfoliated with tne cuticle, and sometimes even with the nails ; but as the follicles have their vital actions re- stored, the hair is reproduced. When, howev- er, the hair falls out in phthisis, diabetes, and other cachectic maladies, no attempt at resto- ration takes place. Alopecia may also be symp- tomatic of chronic inflammation of the digestive mucous surface ; indeed, this is a frequent cause of it. The connexion of this state of the digestive organs with chronic cutaneous eruptions is fully established and well known ; and the pilous follicles are sometimes the parts of the integuments affected thus sympathetical- ly ; the affection implicating them either prin- cipally or solely, or in conjunction with oth- er parts of the skin. This dependance upon, or connexion with derangement of the digest- ive, and even of the biliary functions, should never be overlooked in practice; for, although I cannot agree with Broussais and his follow- ers that the external change is produced by the internal inflammatory irritation, or that the internal complaint is so generally inflammatory 164 HAIR—Loss of—Treatment—Trichomatose. in its nature as they would make it appear, yet I am convinced that there is a very close con- nexion often existing between the internal and external affection, both affections generally proceeding from, and being associated by the same pre-existent disorder; which disorder may generally be referred to the state of or- ganic nervous function or power. 32. Treatment.—A. In limited or partial alopecia, more particularly that variety usually called porrigo decalvans, and in all those cases that appear independently of inflammatory ac- tion, that depend upon the first and second pathological states enumerated above (§ 30), stimulation of the parts, by the decoction of walnut-tree leaves, or of the leaves of the so- lan um ; by the infusion of rosemary, or of the lesser centaury, or of mustard-seed ; by various spirituous and aromatic washes ; by ointments containing the tincture of cantharides, or some essential oils; or by embrocations of thyme, lavender, the juice of onions, of garlic, &c, has been very generally recommended. M. Rayer, however, does not consider this practice very successful. Dr. Willis has seen the common mercurial ointment prove of service. An oint- ment, with the iodide of sulphur (3j. of iodide to 3vj. or ?j. of ointment), may be rubbed on the part night and morning. This ointment has been much employed by me in affections of the skin and scalp since 1824. The balsam of sulphur, applied to the scalp, is praised by Ruland ; a solution of the sulphate of copper in spirits, by some recent writers ; and blisters, by Arndt. I have seen a strong solution of the nitrate of silver, in some instances, and either an infusion of capsicum, or ointments with the tincture, in others, applied to the af- fected surface, and persisted in for some time, restore the hair. Dupuytren generally pre- scribed an ointment with a strong tincture of cantharides. I have, in several cases of bald- ness, of the kind under consideration, employ- ed an ointment containing the balsam of Peru with complete success. It has the effect of rendering the hair thick and persistent, and of promoting the growth of it in parts from which it had fallen out from impaired action of the follicles The following is the formula that I have usually employed : No. 244. R Adipis Praeparatae fij.; Cerae Albas Jss.; lento igne simul liquefac, turn ab igne remove, et, ubi pri- mum lentescant, Balsami Peruviaui veri 3ij. ; Olei Lavan- dulae tltxij., adjice, et assidue move donee refrixerint. 33. When alopecia proceeds from eczema, impetigo, fevers, &c, the treatment should be entirely directed to the removal of these erup- tions. When this is accomplished, and the skin remains dry, tense, or furfuraceous, the part should be shaved, and the surface anointed with the above ointment, or with some sub- stance of a similar nature, as an ointment with the oil of mace, &c. The tincture or infusion of tobacco, as recommended by Zacutus Lusi- tanus, and often empirically resorted to, will also be of service in this and in some other states of the disorder. In every form of the affection, the digestive, assimilating, and ex- creting functions should be regulated or assist- ed ; and associated internal congestions, or inflammatory irritations, removed by appropri- ate means. Alopecia, as well as premature grayness of the hair, is often caused by disor- der of these functions, and associated with these internal diseases; and neither the one nor the other can even be retarded in their prog- ress, unless the treatment be directed with a strict reference to these pathological connex- ions. Bibliog. and Refer.—Hippocrates, ExiSnuiuv, 1. vi., sect, vii., viii.—Galenas, De Med. Soc. Loc, 1. l.; et Meth. Med., xiv., 18.—Cehus, 1. vi., 4.—Paulus ASgin., 1. iii., c- 1. —Aitius, 1. vi., s. 65.—Actuarius, Meth. Med., 1. ii., cap. 5 ; 1. vi., cap. 1.—Oribasius, Synop., 1. viii., 22.—Mesue, L. ii., serm. i.—Avicenna, L. iv., fen. 7, tr. i., ch. 5.—Leo Africanus, Descriptio Africae, 1. i., p. 85.—Fernelius, Con- sil., i.—Joubert, De Affect. Pilorum et Cutis praesertim Ca- pitis, 8vo. Lyon., 1577.—Ampsing, Hortus Affect. Capil- los et Pilos Corp. Hum. Infcstantium, 4to. Rost., 1623.— Mercuriali, De Morb. Cutan., 1. i., cap. 3-5. — Merlet, Ergo a Salacitate Calvities. Paris, 1662.—Plempius, De Affect. Capillorum et Unguium. Lov., 1662.—J. Burlin, De Fas- minis ex Mensium Supp. Barbatis, 4to. Altd., 1664.— Za- cutus Lusitanus, Prax. Hist., 1. vii., obs. i. ; Prax. Admir., 1. ii., obs. 129.—fi. Tyson, Philosoph. Trans., 1678.— Schenck, Observ. Med. Bar., 1. i., ohs. 3.—Hagedorn, Hist. Med. Phys., cent, iii., p. 354.—Glisson, De Vent, et Iutest., tr. i., cap. 10.—Rulani, Cent, viii., cur. 49, 65.—Heister, Misc. Nat. Cur., dec. i., an. ii., obs. 193.—Paulini, Cent. iii., obs. 60.-Riedlin, Lin. Med., 1695, p. 439; 1700, p. 341.—Lemery, Hist.de l'Acad. des Sciences, &c, an. 1702, p. 29.—Alberti, De Canitie prematura. Halae, 1721.—Me- ibomius, De Piliseorumque Morbis. Helmst., 1740.—Schei- demantel, Beytrage, n. 36.—Lorry, Tract, de Morbis Cu- taneis, p. 402.—Ludwig, Primae Lineae Anat. Path., p. 29.— Haller, Elem. Physiol., vol. v., p. 32.—Morgagni, Epist. viii., art. 7.— Werlhof, Observ. de Febr., sect, vi., sc. 7.— E. G. Bosc, Program, de Praeternat. Pilorum proventu, 4to. Leips., 1776.—Brouzet, Sur l'Educat. Medicinale des En- fans, t. i., p. 396.—/. P. Frank, De Cur. Horn. Moib., t. iv., p. 120.—R. How, in Mem. of Med. Soc. of Lond., vol. iii., p. 515.—Lanoix, in Mem. de la Soc. Med. d'Emulation, t. i., p. 1.—Moreau, in Ibid., t. ii., p. 196.—Wells, Trans, of a Soc. for the Improvem. of Med. Knowledge, vol. ii., p. 264. —Boehmer, De Dignitate Pil. Remediisque, eorum Incre- mentum, et Promoventibus, et Impedientibus. Viteb., 1798.—/. P. Pfaff, De Varietatibus Pilorum Naturaliliuset Praeternaturalibus. Halae, 1799.—Danz, in Stark's Archiv. f. d. Geburtshiilfe, b. iv., p. 684.— Voightel, Handb. der Pathol. Anat., 8vo. Halie, 1804, b. i., p. 85.—Mangili, Sulla Calvezza Ereditaria, in Giorn. della Sue. Med. Chir. di Parma, vol. viii., p. 57.— Bichat, Anat. Generale. t. iv., p. 327.—Brilckmann, in Horn's Archiv. fiir Med. Erfahrung, 1811, b. ii., p. 69.—Matthaei, in Hufeland's Journ. d. Pract. Heilk., b. xvi., st. 3, p. 67.— Westphalen, in Ibid., b. xx., St. 4, p. 81.—G Wedemeyer, Hist. Pathol. Pilorum, 4to. G6t., 1812.—Macartney, art. Hair, in Rees's Cyclopaedia.—Rich- erand, Elem. of Physiology, a- ?iaia, 'HutKpavta (from rjpt, half, and npavtov, the scull). Cephalalgia, Cephalaa, Hemicra- nia, Auct. Lat. var. Dolor Capitis^ Sennert, &c. Dolor Cephalicus, Hoffmann. Capiple- nium, Baglivi. Gravedo Capitis, Carebaria, Kapnfmpta (from Kapy, the head, and Bapvc, heavy), Podagra Capitis, Clavus, Clavus Hys- tericus. Mai de Tete, Cephalalgie, Migraine, Fr. Kopfschmerz, Hauptwehe, Germ. Mai di Capo, Cefalea, Ital. Pain in the Head, Megrim. Classifica. — 4. Class, 4. Order (Good). IV. Class, III. Order (Author.) 1. Defin.—Pain in the head, with intolerance of sound, sometimes also of light, and incapability of mental exertion. 2. Headache has too generally been referred to disorders of those viscera of the abdomen with which the head sympathizes, even when manifestly proceeding from morbid states of parts enclosed by the cranial bones. It should, however, be recollected that the primary affec- tions, of which headache has been viewed as a symptom merely, much more frequently exist without than with this attendant; and that, when thus accompanied, some pre-existent or contemporaneous affection of the head is often actually present, either independently or as an intimately related complication of these repu- ted primary disorders, and is only aggravated or rendered more manifest by them. Besides —and the circumstance cannot be too strongly impressed upon the young practitioner—those very disorders so generally considered the source of headache are not infrequently pro- duced by an affection of the brain; for pain of the head, although a common symptom of it, is neither universally nor constantly present, but is very frequently altogether wanting at an early or an advanced period; so that disease of the brain itself may, in the first place, disor- der the digestive or other functions, this dis- order reacting upon the brain, or on the nerves more immediately related to it, and exciting or otherwise altering their sensibility, so as to give rise to headache and other symptoms ac- tually depending upon the brain, although de- veloped and rendered manifest by the sympa- thetic disturbance of the digestive organs. When this takes place, the means of cure di- rected to the supposed primary disorder, but really to the symptomatic affection, by remo- ving it, and by modifying the current of the cir- culation, frequently relieves the disease of the brain, as far as morbid sensibility is concern- ed ; and the relief is more or less complete or permanent, according as the prescribed means affect both the symptomatic and the primary disorder. That secondary or sympathetic af- fections are often thus mistaken for the prima- ry, will be manifest to every experienced and acute practitioner upon reading Dr. Warren's paper on headaches; for many of the symp- toms he has enumerated as indicative of pri- mary disorder of the stomach and intestines are often either dependent upon the state of the circulation within the head, or associated with an affection of this part, and are resulting phenomena of previous disorder of the organic nervous system. 3. The dependance of disorder of the di- gestive organs and of the altered sensibility of the head upon the state of organic nervous in- fluence has been overlooked by pathologists, owing to the brain having been generally, but erroneously viewed as the source of nervous and vital energy, and to the dominion which the stomach has been supposed to exercise over the functions of other organs through the medium of the brain. But it has been shown in another place (see art. Debility, Disease, &c), that the brain performs other offices than that of generating organic, nervous, or vital power; that it is enabled to perform its appro- priate offices by the vital influence it derives from the organic nervous system; and that the stomach is dependant upon the same source as the brain for the discharge of its functions. Instead, therefore, of considering headache to proceed so frequently from disorder of the di- [ gestive organs, as some recent writers sup- 168 HE ADACHE—P ath olog y. pose, I view both the one affection and the other as often associated phenomena resulting from other morbid conditions; and while I grant that it sometimes arises from that source, I contend that it then appears as a contingent phenomenon only, for when one part of the cir- cle of organic nervous influence is disturbed, other parts frequently become also disordered. as hereditary constitution, previous disease, latent vice, or habits of life may have predis- posed particular organs or structures. More- over, it seems extremely probable that various morbid states of parts contained within the cranium are indicated by pain before they have proceeded so far as to induce change of struc- ture, or even without occasioning this result. The existence of altered sensibility of the ganglial nerves, distributed to the head, may be admitted without any very evident alteration of the parts they supply being thereby induced. Observation has proved that the degree of pain is no index to the danger or extent of disease, as the most severe headaches are often unat- tended by any other evidence of organic le- sion ; while the most extensive disorganization is frequently accompanied by little or no head- ache. 4. From this it will appear that headache should be viewed as a symptom of disorder within the cranium, although not of altered structure, more frequently than it usually is; that it should be oftener assigned to a change in the organic nervous energy and sensibility in this situation; and, consequently, that it is oftener a primary disorder than it has been generally considered. In treating, therefore, of headaches, I shall view them with strict reference to pathological states. Some of these states are such as do not admit of the headaches they produce being viewed other- wise than as symptoms ; but others allow a nearer approach to a primary or idiopathic form, especially where local or general causes of exhaustion or depression occasion the com- plaint. 5. When called to a person suffering, or lia- ble to severe headache, the rational practition- er is led to inquire as to the causes and seat of pain, and as to its nature. But these are among the most difficult points to determine in prac- tical medicine. The causes are most numerous and diversified, and yet they have a more or less intimate relation to the kind or form of the pain that results. The seat of pain is deter- mined with great difficulty even when it admits of recognition, and in many cases it is impos- sible to ascertain it with any degree of precis- ion. In order to arrive at a just conclusion, a number of circumstances—the history of the case, with its causes and progress, the existing symptoms, and more especially those which more directly relate to the functions of diges- tion and excretion, and to perception, sensa- tion, and locomotion—must be carefully ob- served and cautiously estimated. When the -external or superficial parts of the head are •chiefly affected, the exact seat and nature of the disorder are sometimes manifest. But, •even in this case, the external affection may be only the consequence of previous disease of internal parts, the exact nature or seat of which *ean be only surmised in many instances. Dis- ease of the membranes is generally attended by pain ; but when it is chronic, and even when acute, if pressure of the brain is caused by it, no headache may be felt. When the more internal parts, especially the fibrous or medullary structure, are altered, pain is only an occasional symptom. Indeed, whenever the substance of the brain is chiefly affected, the pain should be ascribed rather to those parts of the membranes, or of the ganglial nerves supplying the brain that had become implica- ted in the disease, than to the brain itself. Al- though it is the brain that feels alteration of sensibility induced in morbid parts, yet its own sensibility is so obscure, or so deficient, as sel- dom to be either excited or perverted when itself is the seat of lesion. Besides this, when the disease of the brain is attended by pain, the pain is rarely referred to the internal parts of the head, but either to some superficial sit- uation, or to the head generally, in a confused or indistinct manner; or to some more or less distant part having an intimate nervous con- nexion with the seat of disease. 6. The difficulty of ascertaining the nature of headache cannot be considered so great as that of determining the seat of it. Indeed, it is often from inferences as to the nature of headache that we are enabled to form any no- tion of its seat. A careful inquiry into the caus- es of the pain in every case, and a due esti- mate of the constitution, habits of life, previous ailments, and existing state of the patient will generally enable the physician to determine as to which of the different forms of the com- plaint into which I have divided it individual cases belong. The kind of pain, especially, should be inquired into with the utmost precis- ion. Its severity, its character, the state of the senses and of the general sensibility, the temperature of the scalp, &c, ought to be as- certained. The pain may be either slight or intense, or characterized as heavy, dull, indis- tinct, diffused, numbing, compressive, constrict- ive, tensive, acute, burning, rending or burst- ing, or splitting, darting, lancinating, plunging, cutting, tearing, gnawing, boring, pulsating, or throbbing, &c. ; but whichever of these may exist, the mode of its accession and subsidence; its duration, remissions, and exacerbations; the circumstances alleviating or aggravating it; the extent and situation of it; and its con- nexion with affections of sight, with noises in the ears—the character of these noises—and with derangements of sensation, touch, and muscular action in any part of the body, ought to be carefully remarked. The state of the mental operations, of the articulation, and of sleep in respect both to its manner and dura- tion, should also receive attention. It is only from a careful estimate of these circumstan- ces—of all the functions depending upon the cerebro-spinal system in connexion with the state of the digestive, excreting, and circula- ting functions—that a correct opinion as to the nature of headache can be formed. There is no disorder which tries the science, experience, powers of observation, and acumen of the phy- sician more than this does ; and there is none that requires a more precise estimate of the pathological conditions on which it depends, as a basis for safe and successful indications of cure. From this it will appear that a compre- hensive division of the varieties of headache, HEADACHE—Nervous—Congestive. 169 without being either complicated or unnecessa- rily minute, is requisite to the due considera- tion of so important a subject as this. 7. Sauvages divides headache into three spe- cies : Cephalalgia, or acute headache; Cephalaa, or chronic headache ; and Hemicrania, or par- tial or local headache. Under the first he enu- merates the following varieties: the plethoric, catamcnial, hamorrhoidal, dyspeptic, febrile, throb- bing, intermittent, puerperal, inflammatory, catar- rhal, nervous, hysterical, and the metallic. Under the second species he adduces the syphilitic, scor- butic, arthritic, remittent, melancholic, the Polish or plicosc, and the serous. Under the third, pains of the eyes and sockets, in the frontal sinuses, and the catarrhal and hysterical, hamorrhoidal, purulent, nephralgic. and the lunatic hamicrania. It is obvious that this enumeration is deserving of attention only in as far as it shows the symp- tomatic states of the disease. Sagar adopts the division of Sauvages without any material alteration. J. Frank, also, follows it partially, and enumerates four species, viz., Cephalalgia, Cephalaa, Hemicrania, and Clavus. He consid- ers that headaches, in respect of their nature, may be farther divided into inflammatory, rheu- matic, gastric, arthritic, scorbutic, periodic, scrof- ulous, carcinomatous, syphilitic, and nervous. 8. Dr. Good has taken a very superficial view of the pathology of headache, and the surgical editor of his work has added nothing to the text. He divides headaches into the stupid, chronic, throbbing, and the sick, and megrim. Every practitioner of experience must have met with, if he have not actually experienced in his own person, headaches which at one and the same time possessed all the characters Dr. Good has enumerated as marking distinct spe- cies. Dr. Burder has given a more correct division of the complaint, but it is deficient in some important particulars. The varieties, ac- cording to him, are, muscular, periosteal, congest- ive, organic, dyspeptic, and periodic headache. Dr. Weatherhead divides headaches into dys- peptic, nervous, plethoric, rheumatic, arthritic, and organic. The division adopted by Sauvages is complicated, and, notwithstanding its apparent minuteness, deficient. The arrangements of recent writers are even still more defective. 9. The several varieties of headache will be more advantageously considered according to the following arrangement: 1st. The nervous, from depression or exhaustion; 2d. The con- gestive, from impeded circulation in the brain or its membranes ; 3d. The plethoric and in- flammatory, from general plethora, active de- termination of blood to the head, or inflamma- tory action ; 4th. The dyspeptic and bilious, from disorder of the stomach, liver, or bowels ; 5th. The cerebral, from organic change within the cranium ; 6th. The pericranial, from disease of the pericranium, oriones of the cranium ; 7th. The hemicranial or limited, confined to a spot, or neuralgic ; 8th. The rheumatic and arthritic; 9th. The periodic ; 10th. The hypochondriacal; and, 11th. The sympathetic, from disorder of the uterine and urinary organs. 10. i. Nervous Headache.—A. Causes.—a. This variety is most frequent in females, in persons of the nervous temperament, and in those possessing high susceptibility and deli- cate constitutions. Venereal excesses, mas- turbation, intestinal worms, the abuse of calo- II 22 I mel or other mercurials, and whatever depress- es or exhausts nervous or vital energy, predis- pose to it.—b. It is often excited by exposure to cold, or to cold and humidity conjoined; by northerly or easterly winds ; by the mbre ex- treme electrical states of the air, or by sudden vicissitudes of these states ; by prolonged or excessive lactation; by losses of blood, mon- orrhagia, leucorrhoea, or other discharges ; by low diet and prolonged fasting; by the depress- ing passions, alarm, fear, grief, and anxiety of mind ; by want of sleep, or inordinate mental or physical exertion; by the improper use of mercury or other depressants, as tobacco, dig- italis, &c.; by various odours or mephitic va- pours or gases ; and by the impure air of crowd- ed or insufficiently ventilated rooms. Sleeping in apartments containing plants in flower, the fumes of burning charcoal, or of turpentine, and recently painted rooms, not infrequently cause it. The irritation of adjoining parts, as caries of the teeth and disease of their fangs, sometimes also occasion it, especially on the same side of the head as the seat of irritation. I have seen the most intense state of this af- fection produced by the injudicious application of cold to the head, by too copious depletion, by floodings, and by a residence in low, cold, and humid localities. Nervous headache is common to females during the catamenia, es- pecially when excessive or too frequent. It is often, also, indirectly caused by intoxicating liquors. Heinimann very justly notices it as a not infrequent attendant upon general anamia resulting from disease or improper treatment. I believe that some degree of cerebral anamia very often attends, if it does not produce this variety of headache. 11. B. Nervous headache is often sudden in its attack and termination; is frequently acute, excruciating, lancinating, or darting; some- times constrictive, or attended by a sensation of the temples being pressed together; occa- sionally accompanied with vertigo, a feeling of sinking and dread of falling, or with great ner- vous agitation or restlessness, and sometimes confined or limited to a narrow space. The patient is incapable of thought and of physical and mental exertion. The sight is often dim or impaired, dark spots or meshes moving be- fore the eyes. In some instances, the eyes become sunk, and the countenance depressed or collapsed. The pulse is small, occasionally frequent, but generally languid, and always compressible. The pulsation of the carotids is small or weak. The head is cool, and the face more pallid than natural. The stomach is liable to disorder, especially to acidity and flatulence, and the bowels are often costive. This headache is frequently worse in the morn- ing and through the day, and abates in the even- ing. During severe attacks, wakefulness, diz- ziness, loss of memory, general susceptibility of the nervous system, &c, are usually com- plained of. 12. ii. Congestive Headache.—The state of the circulation within the head, the manner in which the blood is returned from the brain, the partial protection of the parts contained in the cranium from the physical influences exerted upon the rest of the general surface, and the periodical changes in the position of the head and in the exercise of the functions of the 170 HEADACHE—from Plethora, etc. brain, would seem, on a superficial view, to fa- vour the occurrence of congestion in this part. Yet, if these circumstances be more closely contemplated, there is at least equal evidence that they essentially tend to preserve the brain from passive congestion on the one hand, and inflammatory determination on the other, as well as from the more serious contingencies consequent upon that minute division of the extreme vessels required for the exercise of the various cerebral functions. The congestion oc- casioning this form of headache is seldom gen- eral, but commonly limited to, or seated chief- ly in one hemisphere or lobe of the brain, or one or more lobes, either in their vertical or basilar aspect. 13. A. Causes.—Congestive headache is pro- duced by pre-existent disorder, especially by repeated attacks of nervous or dyspeptic head- ache, and of active determination of blood to the brain. It often follows adynamic fevers, phrenitis, congestions of the lungs, and impe- ded circulation through the heart ; and it is not infrequently caused by the circumstances that sometimes give rise to nervous headache, particularly the depressing passions, cold and humidity, miasmata, noxious gases, mephitic vapours, and crowded rooms. The use of opium, belladonna, aconitum, and other narcot- ics, occasionally also produces it, especially in certain idiosyncracies, or in large doses. Tight neckcloths, stooping, and a too low position of the head during sleep, also occasion it. The headaches following the inordinate use of in- toxicating liquors are to be referred to this and the preceding variety, rather than to disorder of the digestive organs or any other pathologi- cal state. Prolonged or intense mental occu- pation often gives rise to congestive headache; the repeated or continued determination of blood to the brain, thereby produced, passing into congestion, owing to exhaustion of ner- vous power; and this state, if allowed to con- tinue, or frequently produced, often terminates in apoplexy or palsy. This variety is most frequently observed in persons advanced in life, and in those who have exhausted their vital energies and injured their constitutions by dissipation or intemperance. 14. B. The most characteristic symptoms of this variety are, the dull, gravative pain, and sense of weight in the head ; frequently stupor, heaviness, or giddiness ; dimness of sight; buzzing, ringing, or humming noises in the ears; and heaviness or pallor of the counte- nance. The pain is often referred to one part of the head chiefly, probably owing to the con- gestion being greater in one part than in an- other (y 12). The patient experiences great increase of vertigo when looking up, or when stooping or looking down from an eminence ; he sometimes complains of a sense of coldness in the head, of fatigue or prostration of strength, coldness of the extremities, and of susceptibil- ity of the nervous system. Sleep is often sound, heavy, or snoring; occasionally it is disturbed or restless, and attended by dreams, or by convulsive movements. The spirits are depressed, or almost hypochondriacal. The pulse is languid, weak, or small, occasionally accelerated. The bowels are torpid, and the biliary secretion deficient or morbid. The urine is loaded, and deposites a copious sediment. I 15. iii. Headache from Plethora and in- creased Vascular Df.termination or Action. — A. The predisposing causes of this variety are, the earlier and middle periods of life, the male sex, plethoric habits of body, sanguineous and irritable temperaments, full living, indo- lence, indulgence in bed, neglect of regular ex- ercise in the open air, and mental exertion.— B. The exciting causes are, all the circumstan- ces which either increase the vascular plethora resulting from the predisposing causes, or de- termine an increased flow of blood towards the head, especially neglect of accustomed depletions ; the suppression of discharges and eruptions, particularly of epistaxis, the cata- menia, and haemorrhoids ; exposure to the sun; intemperance in eating or drinking; premature or inordinate mental culture, and exercise of the intellectual powers ; every kind of mental excitement; fits of passion ; the supine pos- ture, with the head low; wearing strait corsets; too long hair, or the removal of it; overheated or overcrowded rooms or assemblies ; prolong- ed or unaccustomed continence, and the causes usually occasioning inflammation of the brain or of its membranes, or determination of blood to these parts. (See art. Brain, y 182.) 16. C. The Symptoms in this variety suffi- ciently indicate the cause of the headache ; but they differ very much in different habits, tem- peraments, and ages.—a. In young persons the pulse is strong, or full, somewhat accelerated ; the head is hot, the countenance flushed, the eyes more or less suffused and heavy ; and the pain is rending, severe, sometimes pulsative or throbbing, occasionally with a beating noise in the ears, and felt chiefly in the forehead and temples. The bowels are costive ; and the patient is depressed, heavy, and indisposed to exertion.—b. In delicate or young persons, whose mental faculties have been prematurely exercised, or exerted to the neglect of the phys- ical powers, the slightest excitement and the most trifling causes will produce headache, with coldness of the extremities, and great susceptibility of the nervous system, especially of females. The principal flux of the circula- tion takes place to the head, and the functions of other parts are performed imperfectly.—c. In persons of the middle age, or beyond it, and especially in those who have lived fully or in- temperately, the headache is heavy, rending, or throbbing ; often general, or referred chiefly to the occiput; attended with increased heat of the scalp, with distention of the veins about the temples, with fulness or redness of the eyes, and sometimes also of the whole counte- nance. The face is occasionally bloated, and its expression heavy; the pulse is full, strong, and oppressed, or slower than the usual standard; the bowels are torpid, the liver inactive, and the urine high-coloured or loaded. Sleep is heavy, but often disturbed. In some cases, however, with all, or nearly all these symp- toms, the patient is excited or restless, is watchful, or sleeps but little, or is irritable and the pulse is slightly accelerated, the excre- tions being scanty. In the first and second classes ot persons, this form of headache not infrequently precedes the inflammation of the brain and membranes, or effusion from the lat- ter : in the third class, it more frequently ush- ers in apoplexy or palsy. HEADACHE—Dyspeptic and Bilious. 171 17. iv. Dyspeptic and Bilious Headaches. —A. This variety of headache is very nearly allied to the nervous and congestive, and it has been confounded with these in the description of it given by Dr. Warren. From the circum- stance of sickness or vomiting being a frequent symptom, the term sick headache has been com- monly applied to it. But I am convinced that this symptom often depends upon the brain, and that many cases which have been viewed as merely instances of sick headache have ac- tually been cases in which the affection of the brain has been attended both by sickness and by headache (§ 2, et seq.). This form of disor- der frequently affects dyspeptic persons who have been longer than usual without food, or who have committed even slight errors of diet, and whose bowels are habitually sluggish. It may occur, as Dr. Burder remarks, without any obvious susceptibility of the brain ; or in persons who can bear close application to study without inconvenience as respects the head, and yet who are liable to headache after taking certain articles of food, or mingling them in too great variety. 18. a. Dyspeptic headache, particularly when attended by nausea or vomiting, is observed chiefly in persons subject to mental or cerebral excitement, and in whom the gastric disorder, as well as the pain of the head, are only effects of that excitement. In these, the stomach is either irritable or weak, or even both, and unfit to perform its functions, as well as very liable to become farther disordered by slight causes. Stomach headache generally affects the fore- head or one temple, particularly the left; but it often extends over most of the head. When the left temple is chiefly affected, tenderness of the left eye is frequently, also, felt. The pain is dull, heavy, or oppressive, or acute, sharp, or darting. The mental faculties are some- what weakened, and exertion of the mind is irksome. Tenderness of the scalp is seldom present, unless in a slight degree, or in con- nexion with rheumatism. This variety of head- ache usually commences when the patient first wakes. It is then oppressive, heavy, or dif- fused. Nausea often supervenes, and some- times vomiting. When the pain is slight, it generally subsides after breakfast; but if retch- ing occurs, it continues longer, or until offend- ing matters are thrown off, and then becomes more limited or concentrated. The remains of an undigested meal, or merely an insipid fluid, mixed with frothy mucus, is at first eject- ed. But if the vomiting continue, bile is fre- quently discharged. In some instances, an acid or acrid fluid, or greenish bile, is vomited, when pain and all the symptoms disappear. If the attack be not arrested by suitable means, or by the spontaneous vomiting, the pain often increases as the day advances, until stimulating food or beverages taken into the stomach, or sleep, allay it; but it may return the following day. Dyspeptic headache, however, may take place much more slightly and transiently, or it may assume a more chronic or continued form. It may follow a principal meal, and cease in two or three hours ; or it may not occur until several hours after a meal. The pulse is lan- guid or feeble, seldom accelerated. The tongue is white, loaded, particularly towards the root; and its edges are slightly red, and often indent- I ed by the teeth. The bowels are usually cos- tive. Vision is frequently indistinct; and cold- ness or slight numbness of the fingers is some- times complained of. 19. b. It has been supposed by Dr. Warren and Dr. Paris that, when the headache does not occur until several hours after a meal, and particularly when uneasiness or a sense of dis- tention is felt in the situation of the duodenum, it depends upon irritation of this viscus. The circumstance of an emetic often failing to afford relief in such cases, or to evacuate anything material from the stomach, while a dose of rhubarb and magnesia, or of any other purgative, generally removes both the headache and the uneasiness in the course of the duodenum, has been considered as proof of the dependance of the affection of the head upon disorder of this bowel. Without questioning the existence of functional disorder of the duodenum in these cases, the origin of the headache in that disor- der does not necessarily follow. Both affec- tions, most probably, depend upon the same pathological states; and it is, moreover, ex- tremely likely that the derangement of the duo- denum extends more or less to both the stom- ach and liver. The symptoms which the wri- ters just referred to consider characteristic of headache proceeding from disorder of the upper portion of the intestines—particularly chilliness of the body; coldness and dampness of the hands and feet; severe pain of the head, with a sense of coldness and tightness of the scalp ; slight giddiness, with weight, distention, and stiffness of the eyehrills, and the appearance of brilliant ocular spectra ; and sometimes tin- gling and numbness of the fingers and hands —arise as much from disorder of the stomach or liver, or both, as from derangement of the duodenum and upper parts of the intestines. More dependance may, perhaps, be placed upon flatulency and the sensation of dryness and in- activity of the bowels noticed by Dr. Paris, and upon the presence of nausea without vom- iting ; but it is most probable that the altered sensibility referred to the head, equally with the symptoms just mentioned, depends prima- rily upon the state of organic nervous influence. 20. B. Biliary derangement is generally con- nected with more or less disorder of the stom- ach and bowels ; the affection of the one may have extended to the other, or all may have been simultaneously disturbed by causes affect- ing the nervous or the vascular systems. In either case, the disturbance is not infrequently, also, extended to the head, and partly mani- fested by pain in this situation, particularly in the forehead, eyebrows, and orbits.—a. The headache may proceed from an interrupted dis- charge of bile into the duodenum, and a conse- quent accumulation of it in the gall-bladder or hepatic ducts; the morbid impression thereby made upon the organic nervous system affect- ing the head, and often, also, other remote parts. When the headache arises from this state of disorder, vascular action is generally weak, languid, or depressed, the tongue loaded or white, the skin harsh or unhealthy in its hue, and the functions of digestion and faecation impaired. In these cases, flatulence, coldness of the extremities, and a sense of smarting in the eyes and eyelids, or pain in the eyeballs, are often, also, complained of. 172 HEADACHE—from Disease of the Periosteum, etc. 21. b. In some instances, headache proceeds from an exuberant secretion of bile, or from the irruption of morbid bile into the duodenum; but, in most of these, there are increased vas- cular action and heat of skin, with nausea and bilious vomitings. The face is flushed, the eyes suffused, and the pain is throbbing or rending. The evacuation of bile often gives relief, but the retchings sometimes keep up the secretion, or promote the discharge of it; and the digestive mucous surface, and the nerves supplying it, being thereby irritated, vascular action becomes excited, and the sensibility even of remote parts more or less altered : pains of the head, loins, and limbs are thus induced. 22. C. The Causes of dyspeptic and bilious headache have a very intimate relation to the predisposition or susceptibility of the nervous systems and digestive organs to excitation or irritation.—a. Such susceptibility very often exists in a high degree in persons of sedentary and studious habits. Intense application of the mind, the anxieties of parents, the eager pursuit of business or of gain, the speculations of merchants, the gambling transactions of the stock-markets and of club-rooms, &c, keep the mind in an almost constant state of excite- ment, determine an augmented flow of blood to the brain, and thereby increase the irritabil- ity of the stomach, and predispose both organs to be disordered by the slighter causes to which the latter is so much exposed. As vital power becomes weakened, the susceptibility of the cerebro-spinal nervous system is increased, and the sensibility of it more readily disturbed. The digestive and assimilative functions are also weakened, and more prone to disorder, which not infrequently affects the brain, espe- cially when its circulation has been excited, or kept in an almost constant state of erethism, by the circumstances just adverted to. Dys- peptic headache is most common in the young or middle-aged. The bilious variety is most prevalent during summer and autumn. 23. b. The exciting causes are, errors in diet, especially too great a variety or quantity of food ; indigestible, acrid, cloying, rich, or heavy articles ; too long fasting; the excessive use of diluents or of stimulating or intoxicating beverages, particularly of spirituous liquors; costiveness or constipation, and the irritation of morbid secretions and faecal matters retained in the bowels. In young persons, especially, headache and increased determination of blood to the head are frequent consequences of cos- tiveness, of collections of sordes or of faecal matters in the digestive canal, and of intestinal worms. 24. v. Headache from Organic Changes.— In the early stages, this form of headache can hardly be distinguished from the other varie- ties ; indeed, organic change not infrequently originates in some one of the pathological states of which headache is an occasional at- tendant. But, while in all these varieties the pain is only sometimes present, or is, at least, entirely absent for considerable periods, that produced by organic lesion is nearly constant or continued, or merely remits, without alto- gether disappearing. The alterations which are attended by headache are numerous; in- deed, all those enumerated in the articles Brain (y 3-133) and Cranium may give rise to it; but the most common are tumours of vari- ous kinds, hydatids, exostosis from the inner surface of the cranium, ossific formations, soft- ening of the substance of the brain, suppuration, adhesions of the membranes ; tubercular, can- cerous, fungous, and malignant productions, &c. Besides these, aneurismal or ossified ar- teries, varicose or inflamed veins, obstructions in the sinuses and veins ; concretions, albu- minous exudations, or purulent matters in these vessels (Lieutaud, Borsieri) ; enlargement of the pineal or pituitary glands, serous effusion, &c, have been observed. 25. The pain caused by any of these lesions is generally fixed, often referred to the same spot, continued, and deep-seated. It is inde- pendent of the other causes of headache, al- though aggravated by them, by mental applica- tion, by stooping, and by stimulants. Dr. Bur- der justly remarks that cheerful conversation that would chase away, or at least suspend the feeling of ordinary headache, often becomes in- supportable in this variety. When the disease is farther advanced, even a slight motion of the head, or rotating it, often gives rise to ex- treme suffering, and sometimes to vomiting. The affection of the stomach, dependant upon the cephalic lesion, frequently occurs without any obvious cause, or independently of appa- rent disorder of the stomach itself, or of any error in diet; and the pain of the head remains when the sickness ceases. Although the pain is generally constant, yet remissions are some- times felt, or even short intermissions, espe- cially early in the disease. This is even the case when the lesion is malignant or carci- nomatous, or consists of fungous tumours; and the pain is usually then lancinating, stounding, or darting, and referred to a particular spot. In the advanced stage of organic headache, spasmodic contractions of the limbs, vertigo, convulsions, paralysis, or idiotism frequently supervene. When the lesion is of a malignant or contaminating nature, the surface generally assumes a pale straw-coloured hue, or is ob- viously cachectic. Neuralgic pains in the face, or in more remote parts, darting pains in the limbs, are also occasionally present in this variety. (See arts. Brain—Softening of, &c, and Palsy.) 26. vi. Headache from Disease of the Pe- riosteum and Cranial Bones.—This variety is not often met with. Cases of it have been recorded by Mr. Crampton, Sir E. Home, Dr. Abercrombie, and others; but the best de- scription of it is given by Dr. Burder.—o. Af- fection of the periosteum is usually caused by exposure to cold, to currents of air, to humid- ity, and vicissitudes of temperature and weath- er. The pain is tensive, remitting, and in- creased by pressure, and by the action of the temporal or occipito-frontalis muscles. There are sometimes fever, and excited action of the vessels of the head, with increase of the heat of the scalp. A constrictive pain is caused or aggravated by going into a cold room, or by removing the usual covering from the head. Dr. Burder observes that this variety of head- ache occurs only in those who have suffered from continued cerebral excitement; and that it is commonly dependant upon a highly sus- ceptible, or preternaturally vascular condition of the brain or its membranes, such as is often HEADACHE—Rheumatic and Arthritic—Intermittent. 173 induced by long-continued study, by mental ir- ritation, or by gastric or hepatic disorder con- nected with debility or exhaustion. If a per- son whose nervous or vital powers are thus impaired, and whose brain and membranes are rendered susceptible and vascular, is exposed to the exciting causes just mentioned, perios- teal cephalalgia of great severity or obstinacy is often produced, the external affection, with the consequent irritation and want of sleep, aggra- vating the morbid condition of the brain and membranes. The cases which I have seen have been chiefly in persons of the scrofulous diath- esis. 27. b. Cases of fixed pain of the head, and tenderness of a portion of the scalp, with thick- ening or swelling of the integuments, have been observed by the writers just mentioned, and by Mr. Pearson and Sir C. B. Brodie. I have seen instances of this affection originate in otitis: one of these was in a medical friend, who consulted also Dr. J. Johnson and Sir C. B. Brodie. The external disorder followed the use of the cold douche or shower-bath, recom- mended for the removal of increased vascular action and heat of the scalp indicative of cere- bral excitement. Division of the pericranium in these cases has generally shown thickening of the periosteum, and even disease of the bone in a few instances. 28. c. When headache is owing to a dis- eased state of the bones (see art. Cranium), there are constant pain and tenderness of a particular spot. Some of these cases originate in syphilitic or mercurial cachexia. Others proceed from inflammation of the ear, and are connected with chronic discharges from this organ, or consist of caries of a portion of the petrous bone, or of the mastoid process. In the cases of this kind which I have seen, there was partial paralysis of the face, with exces- sive swelling around the ear, especially below it, and extending even to the eye. I attended one of these cases with Mr. Barnwell, and another was seen by Sir C. Bell and myself, and is noticed in his work on the nervous sys- tem. Similar instances are recorded, also, by J. Frank and others. 29. vii. Rheumatic and Arthritic Head- ache.—A. Rheumatic Headache is usually caused by exposure to cold, or to cold and humidity, or to currents of air ; by uncovering the head when perspiring; by sleeping on a damp pil- low ; by the passage of air through a carriage window; by sudden vicissitudes of tempera- ture or of weather, especially by easterly or northerly winds. But a predisposition arising out of the rheumatic diathesis, or of disorder of the digestive organs—particularly torpor of the liver, accumulations of bile in the bile pas- sages, and collections of sordes in the intesti- nal canal—is often necessary to the production of this affection of the head. 30. Rheumatic headache is often preceded by a sense of coldness over the head and face, especially on one side. It is seated chiefly in the aponeurosis of the occipito-frontalis and temporal muscles; but it is not always con- fined to this structure, it being sometimes as- sociated with increased vascular determination to the membranes of the brain. The pain is severe, heavy, distracting, or aching, and in its uncomplicated state is attended by a sense of coldness, by great tenderness of the scalp, by rheumatic pains extending down the neck, or in one side of the neck, or in one shoulder, or in the face ; sometimes by copious perspira- tions, and more rarely by rheumatic inflamma- tion of one or both eyes. It is generally ag- gravated in the evening, and alleviated in the morning, and by warmth. There is no in- crease of the temperature of the scalp, or aug- mented action of the arteries of the head, un- less the affection be complicated with excited vascular action in the internal membranes. If it be thus complicated, these symptoms are also present; and, as Dr. Elliotson justly ob- serves, there are likewise giddiness, drowsi- ness, and internal throbbings. This associated disorder is seldom ameliorated by warmth, and the face is often flushed, the eyes injected, and the vessels loaded. 31. B. Arthritic Headache is met with in per- sons who are subject to the irregular forms of gout; and, in those who have an hereditary or an acquired predisposition to this malady, it may be the first manifestation of the gouty af- fection. Of this I have seen more than one in- stance, both in males and in females about the change of life. It is not an unusual form of misplaced or of retrocedent gout, in persons who have had the disease in its more regular forms, but who neglect the air, exercise, and regimen necessary to the development of a regular paroxysm ; and it is often a dangerous affection. The pain is severe, and attended by a sense of fulness and of heat or burning in the head ; by remarkable tenderness, and by increased heat of the scalp ; by giddiness, dim- ness of sight, and fear of approaching insensi- bility, especially upon stooping; by sounds in the ears, great acuteness of hearing, and intol- erance of noises ; by flushes of heat in the face ; by irritability of temper and restlessness; and by confusion of thought and loss of mem- ory. There are also flatulence and disordered digestion ; costiveness ; a morbid state of the stools, and of the biliary secretion ; and scanty, high-coloured urine, which deposites a copious reddish sediment. The tongue is generally loaded, and its papillae excited; and the pulse is either natural, as to frequency, and full, or accelerated and hard, or oppressed. If this affection is not removed, it may pass into effu- sion, with comatose or apopletic symptoms. (See Gout—Irregular Forms o/, § 16 ) 32. viii. Intermittent Headache.—Cepha- lalgia Periodica, Auctorum—Febris Intermittens Cephalica larvata, J. Frank—usually presents the same characters as the functional varieties already described, especially the nervous and dyspeptic, and differs from them only in re- spect of periodicity. But it may be not merely functional ; for the pain caused by chronic in- flammation of the membranes, or even by or- ganic lesion within the cranium, may assume, at their early stages, an intermittent type. A strict investigation of the causes, and of the states of the various functions, is therefore requisite to a knowledge of the nature of the affection. When the headache proceeds from terrestrial exhalations, or from cold, raw, east- erly or northerly winds, and attacks persons who have been affected with agues or remit- tent fevers, it generally returns daily, either in the morning or about noon; but it may observe 174 HEADACHE—Neuralgic—Diagnosis. a tertian or quartan form. It is often limited to a particular part of the head—frequently to the forehead, or to one brow, or to the brow and orbit—brow-ague. It is sometimes seated in one half of the head. The pain is occasion- ally so severe and so limited in extent as closely to resemble neuralgia. Indeed, inter- mittent headache and neuralgic affections al- most insensibly pass into each other, the parox- ysms of the latter being, however, much more intense and of shorter duration tha"h those of the latter; and they both frequently proceed from the same predisposing and exciting caus- es, namely, disorder of the stomach, bowels, and biliary organs, and exposure to malaria, or to cold damp winds, &c. 33. ix. Hysterical and Sympathetic Head- ache.—The pain in the head is one of the nu- merous forms in which hysteria manifests it- self. It is generally limited to a small space, or to a single spot; and is often described as resembling a wedge or nail driven into the cra- nium or pressing upon the brain—Clavus, &c. It is commonly sympathetic of irritation of the uterine organs, and associated with irregularity of the uterine discharge ; with painful, scanty, or excessive menstruation, or with leucorrhcea; and with flatulent borborygmi, or with the glo- bus hystericus. I have seen it also connected with worms in the intestines, with the irrita- tion of calculi in the kidneys, and with tender- ness and other indications of inflammatory ir- ritation of parts of the spinal chord and mem- branes. Indeed, affections of the spine seldom exist without pain in the head, in some one of its forms, being occasionally felt. 34. x. Hypochondriacal Headache. — Pain of the head is often one of the most distressing symptoms of which hypochondriacal and mel- ancholic persons complain, and is exaggerated by them into the most intense suffering that can be imagined ; and yet, when their atten- tion is directed to other objects of interest, or when they are otherwise excited, this part of their miseries seems altogether forgotten, or for the time removed. Their minds brood upon the cause and consequences of the pains re- ferred to this situation, until they firmly be- lieve the very worst results. A pa'.ient, some time since, called upon me to know whether or not I considered the pain to depend upon or- ganic change; and although my opinion was that this was not the source of the affection, yet several visits were afterward made to me with the same object. Another more recently came under my care, with the firm belief that the headache would terminate in insanity or idiotism. Such cases are, however, not rare ; and although the fears, which subsequently be- come the firm convictions of the patient, are fulfilled in some instances, or even impel them to suicide in others, yet recovery is not infre- quently effected by judicious treatment and management. The source and character of the pain in such cases are ascertained with difficulty, as the patients' accounts are often exaggerated, but are most frequently depend- ant, as far as I have observed, upon the state of the nervous system, in connexion with chronic disorder of the digestive canal and bil- iary organs. The organic nervous energy is manifestly impaired, and all the functions which chiefly depend upon it. But I have seen cases furnishing evidence of congestion, or of chronic inflammatory action of the brain or of its membranes, and have found a treatment based on this view more or less beneficial. 35. xi. Of Hemicrania, and Partial and Neuralgic Headaches.—These can scarcely be considered as distinct varieties of head- ache, inasmuch as the pains proceeding from the pathological states which have been passed in review are very frequently limited in ex- tent, or confined to one side of the head, or af- fect it chiefly. This is especially the case with the dyspeptic, the bilious, the organic, the ner- vous, the rheumatic, the intermittent, and the hysterical varieties ; and it is still more so in respect of that, upon which a few observations remain to be made—the neuralgic.—A. This variety is characterized principally by the in- tensity of the pain, which is confined to a sin- gle spot, or extends in the course of a single nerve. The pain comes on in violent parox- ysms, is of short duration, and is followed by distinct, and often by considerable intermis- sions. There is generally increased sensibil- ity or tenderness of the scalp around the seat of suffering, and the digestive organs often betray disorder. The nervous system is sus- ceptible and weakened. The pulse is seldom materially disturbed. This is only one of the numerous situations in which Neuralgic Af- fections (see the article) manifest themselves. 36. B. Partial or limited Headache is often excited by local causes of irritation. Very se- vere pain in the situation of the frontal sinuses has been experienced, owing to the ova of in- sects having passed by the nostrils to this part. Ploucquet gives numerous references to cases where the larvae of insects had occasioned in- tense pain. A servant in my own family suf- fered from this cause, the larva being dischar- ged upon a violent fit of sneezing. Caries, or disease of the fangs of the teeth, is often the cause of partial headache, the pain being some- times confined to a single spot on the same side of the head as that in which the cause of irritation is seated. 37. xii. Diagnosis.—There is no class of af- fections which requires greater discrimination than this; and there is, perhaps, none which is esteemed more lightly by practitioners, or more empirically treated, the digestive organs being considered much too generally as the source of disorder. I believe that a careful investigation of the cases, and close observa- tion of the juvantia and laedentia, will show that a greater number of them depend upon chronic inflammation of the brain, or of its membranes, than is commonly supposed. The diagnostic symptoms of each variety have been enumerated in the description of it, but the following summary may be given at this place: (a) Nervous headache is distinguished by absence of constitutional disorder, by susceptibility of the nervous system, by the feeling of constric- tion, and the limited extent of the pain, by the natural temperature of the head, &.c. (y 11) — (b) The congestive is characterized by the numb, dull, or heavy, oppressive, and deep-seated pain; by languor of the circulation ; by pallour or heaviness of the countenance; by dizziness, drowsiness, and want of animation; by the coolness of the scalp, and sometimes by ful- ness of the eyes and a bloated state of the face HEADACHE—Prognosis—Treatment. 175 (*. 14).—(c) Plethoric and inflammatory headache is manifested by the general, severe, rending, and throbbing pain ; by nausea or vomiting ; by fulness of the vessels, or flushing of the face and eyes ; by the full, hard, or oppressed pulse ; and by the increased temperature of the head (y 16).—(d) The dyspeptic and bilious is evinced by dull, aching, or racking, or shooting pains, which move from one part to another, and are often attended by soreness of the scalp, by dis- order of the digestive organs, and flatulence ; by a loaded tongue, foul breath, and a morbid state of the secretions, especially the biliary (y 18-21).—(e) The organic is distinguished by internal acute pain, which becomes more and more constant or prolonged ; by sudden retch- ings ; by a quick, irritable, or irregular pulse ; by the pain darting or shooting from one situ- ation ; by tenderness or soreness on pressure being felt, particularly when the bones are af- fected ; by alterations in the sensibility and motions of a limb or limbs; and by sympto- matic pains, spasmodic contractions, &c. (y 25). —(/) Rheumatic and arthritic headaches are readily recognised from the diathesis of the patient, and from the causes and characters of these affections. The rheumatic is generally connected with rheumatism of an adjoining part (y 30). The arthritic presents symptoms that cannot be mistaken, especially when viewed in connexion with the history of the case (y 31). The description of these, and of the other forms of headache, has been so fully given, that nothing farther respecting their diagnosis is requisite. 38. iii. Prognosis.—A favourable result may be anticipated of cases of the nervous, the dys- peptic, the bilious, the rheumatic, the aguish. and the hysterical headache. A guarded opin- ion should be given respecting the inflamma- tory, the arthritic, and the rheumatic when as- sociated with increased vascular action in the internal membranes (y 30). When headache is accompanied with vomiting, without obvious disorder of the stomach having preceded the attack, an inflammatory affection of the brain should be suspected, and a prognosis conform- able with this view ought to be given. A still more unfavourable opinion should be enter- tained if the locomotive powers, if the memory, if the senses, or if utterance or articulation become impaired. If there be sufficient evi- dence of disease of the brain, or of its mem- Vanes, great danger exists, although a fatal termination may be long delayed, or even de- ferred for some years, as in cases of palsy. If the pericranium be affected, and especially if the bones of the cranium be diseased, a very guarded, if not a very unfavourable, prognosis is necessary. 39. xiv. Treatment.—It is evident that the indications for the cure of headaches should be inferred from the nature of each; that reme- dies ought to be directed to their pathological conditions and relations, ascertained by a close examination of the states of the organic and locomotive functions, of the senses, and of the mental manifestations. And, although what has been advanced above may aid the inexpe- rienced, or furnish useful suggestions to many, yet the successful administration of remedies in these affections will entirely depend upon accuracy of observation, and upon pathological and therapeutical knowledge previously ac- quired.—A. Nervous Headache, proceeding from depression or exhaustion, obviously requires the nervous energies to be restored by tonics and stimulants. These medicines, however, should be administered with due caution at first; as the more active of them, or too large doses, may excite fever, or even occasion vas- cular determination to the head. They ought not to be given, or continued long, until faecal accumulations have been removed by mild or stomachic purgatives, which should afterward be prescribed occasionally, in conjunction with deobstruents, in order to preserve the excreting functions in a state of healthy activity. While the head ought not to be kept too warm, the impression of cold must be prevented, at least until the organic functions have acquired their usual tone. In most instances, the milder tonics may be given, with the alkaline carbon- ates, or the aromatic spirit of ammonia, and with carminatives. The diet should be light and nourishing, the occasional causes avoided, and gentle exercise in the open air daily taken. In slight cases, these means, and a due regula- tion of the digestive functions, will remove the disorder; but, if they fail, those about to be noticed should be resorted to. 40. Nervous headache may prove obstinate, or it may be unusually violent from the com- mencement, or gradually become so. If, in these cases, the symptoms, especially those connected with the organic functions, and with the senses and cerebral manifestations, evince neither vascular action nor organic lesion within the cranium tonics conjoined with ano- dynes, antispasmodics, or carminatives, ac- cording to the peculiarities of the case, should be resorted to. The preparations of cinchona, of valerian, of arnica, of asafcetida, and of am- monia ; camphor in full doses; the aethers ; the carbonate of iron, the nitrate of silver, &c, are then severally indicated, and may be given with opium, or with the acetate or hydrochlo- rate of morphia, or with hyoscyamus, or with belladonna, according to circumstances. If there be prolonged watchfulness, a suitable narcotic should be exhibited at, or shortly be- fore bedtime. I have found the following medicines of great benefit in some very severe cases of this kind, the pills (No. 245) having been taken, in addition to the mixture (No. 246), during the violence of the attack. An increased dose of the pills, or the anodyne draught, may also he given at night. Formula 24, 25, 36, 269, 367, 423, 539, 555, prescribed in the Ap- pendix, also, may prove useful in this variety of headache. No. 245. R Camphorae rass gr. xij.-xviij.; Extracti Hy- oscyami Jss.; Conserv. Rosarum q. s. ut fiant Pilule rij., quarum capiat duas, quarta. vel quints, quaque hora. No. 246. R Infusi Valerian* 3x. ; Sodie Carbonafis pr. xij. ; Spiritus Ammonia; foetid. 3j.; Tincturae Lavand. Comp. lUxx.; Tinct. Aurantii Co. Jj. M. Fiat Haustua, quartis, quintis. vel sextis horis sumendus. No. 247. R Quinm;e Stilphatis, Camphors rasw, JJ gr. x. ; Extr. AlotSs purif. gr. xij. ; Extr. Hyoscyami Jss.; Mucilnjf. Acacia q. s. M. Fiant PiluUe xxiv., quarum ca- piat unam, vel duas, vel tres, bis terve in die. 41. B. Congestive Headache should be treated according to the age, habit of body, and consti- tutional power of the patient, and to the local as well as general state of the circulation. It should not be overlooked that vascular action in the brain, owing either to impaired vital 176 HEADACHE—Treatment. power of the capillaries, and of the organ gen- erally, or to impeded return of blood by the veins and sinuses, is insufficient for the due performance of the several functions of this part of the frame.—a. In delicate or irritable persons, stomachic or mild purgatives; tepid or cold sponging the head with fluids contain- ing aromatic and fragrant substances, as laven- der or Cologne water; derivatives, especially warm or stimulating pediluvia; the internal exhibition of camphor, ammonia, valerian, gen- tle tonics, &c.; light diet, and moderate exer- cise in the open air, will prove most service- able. Local blood-letting will seldom be re- quired, even in small quantity ; blisters behind the ears will be productive of benefit in some cases ; and the effusion of tepid water on the head in others. As the patient's strength im- proves, cold sponging the head, or the shower bath, and friction of the scalp, will be useful in preventing a return of the affection. Where there is much irritability, the combination of hyoscyamus, or of small doses of the powder or extract of belladonna, with the medicines just named, and strict attention to diet, air, and exercise, will generally be found of advan- tage. 42. b. When this form of headache affects persons whose vital powers have been exhaust- ed by dissipation and unrestrained indulgences, or those of a leucophlegmatic habit of body, the treatment should be still more restorative, tonic, or stimulant than the foregoing (y 41). Even local depletions will be injurious, and the cold affusion on the head will be of little ser- vice unless the affection has followed the use of narcotics, or when the head is hot. Cordial stomachic aperients, warm spiced wine, or cof- fee ; the preparations of ammonia, or of cam- phor, or of valerian, or of arnica, &c.; stimu- lating pediluvia; and blisters behind the ears, or on the temples, or even on the head, in ex- treme cases, are among the most appropriate remedies in cases of this kind. After these have relieved the more distressing symptoms, the complete removal of the disorder, and the prevention of a return of it, may be attempted by promoting the digestive, the assimilating, and the excreting functions ; by the use of ton- ics, of the preparations of bark or of iron ; and by mild chalybeate and aerated mineral waters. But, before these are prescribed, the secretions and excretions should be freely evacuated, and their morbid states corrected, by alteratives and mild purgatives (F. 205, 266, 430); and, during the course of restorative medicines, these should be frequently resorted to. The factitious mineral waters of Carlsbad, Marien- bad, or of Pyrmont or Spa, subsequently, may be cautiously tried ; but those of Seidschutz or Pullna should, in many cases, precede the use of these. 43. c. When congestive headache occurs in the plethoric, the indolent, and well fed; in persons about or past middle age, or who have experienced obstructions of the liver, or of any accustomed evacuation, the treatment should be very different from the above. General or local blood-letting, the affusion of cold water on the head, brisk cathartics, and derivation to the extremities by warm and stimulating pedi- luvia or manuluvia, are chiefly to be depended upon. But these will fail of being permanent- ly useful, unless the diet of the patient be re- stricted, and regular exercise be taken in the open air. The secretions and excretions ought, also, to be freely and regularly promoted. A daily recourse to the shower bath will prove of great service. 44. d. When this form of headache proceeds from prolonged or intense mental application or exertion, not only should the above means be adopted, according to the age, strength, habit of body, and modes of living of the pa- tient, but entire relaxation of the mind, change of air, travelling, the amusements of watering places, sea voyaging, early hours, light reading, and horse exercise should be enjoyed, as cir- cumstances may permit. At the same time, the mineral waters most suited to the peculi- arities of the case may be taken, especially those that are deobstruent, aperient, and gently tonic ; and, while the functions of digestion and assimilation are promoted by restoratives, and by breathing an open, dry air, the secre- ting and excreting actions of the abdominal viscera should receive strict attention. 45. C. Plethoric and Inflammatory Headache requires the adoption of the means just enu- merated (y 43), but in a much more active man- ner. The regimen ought to be strictly anti- phlogistic, and permanent derivation or coun- ter-irritation established by means of issues or setons in the nape of the neck, or of the tartar emetic ointment, or of croton oil, applied in this situation and in its vicinity. The bowels ought, also, to be copiously and frequently act- ed upon. When this form of headache follows the disappearance of accustomed discharges or eruptions, or of haemorrhages, this treatment should be most strictly enforced, and the use of external as well as internal derivatives stren- uously persisted in. (See Brain—Congestion of, y 139, and Inflammation of, $ 191.) 46. D. Dyspeptic and Bilious Headaches.—a. The former will be remedied by the means ad- vised in the article on Indigestion. I may, however, state in this place, that when this headache is attended by nausea, and when it is clearly ascertained that the sickness does not proceed from inflammatory action within the cranium, an ipecacuanha emetic, vomiting being promoted by drinking chamomile tea or warm water, will generally give relief. After the stomach is evacuated, and the nausea is gone, a mild purgative, as the compound rhubarb pill; or the sulphate of magnesia, with carbonate of magnesia and a carminative spirit or tincture in an aromatic water; or rhubarb, with mag- nesia or an alkaline carbonate, and any aro- matic or carminative medicine, will give far- ther relief by changing the state of the secre- tions in the stomach and upper part of the in- testines, and by promoting the excreting func- tions of the latter and of the large bowels. Ii nausea be not present, these purgatives should be given forthwith, and repeated until the bow- els are freely evacuated. Suitable light diet, exercise in the open air, and an occasional re- course to these or similar aperients will pre- vent a return of the affection. I have found the following most serviceable, when given with this intention, in moderate doses. In lar- ger doses, they will also remove the complaint. No. 248. R Pulveris Rhei 3ss.; Extr. Fellis Bovini, Extr. Aloes punficati, aa 3j.; Saponis Duri gT. xv.; Pulv. Ipa- HEADACHE—Treatment. 177 racuanhse, Pulveris Capsici,aa gr. xij.; Balsami Peruviani, Olei Carui. 5a gutt. viij. Contunde bene simul, et niassam divide in IMulas xxxvj, quarum capiat unam vel duas, cum rrandio, vel horS. somni. No. 249. R Infusi Gentianae Comp., Infusi Sennte Comp., 5a fiij.; Soda; Carbon. 3ij. (vel Magnesia; Sulphatis 3vj.) ; Tinct. Jalap. 3jss. ; Tinct. Sennae, et Tinct. Cardamom. Comp., ft& 31 ijss. M. Fiat Mist., cujus capiat Coch. iij. ampla hora somni, vel Coch. iv. primo mane. 47. b. When bilious headache seems to depend upon the congestion or accumulation of bile in the biliary passages, then chologogues, partic- ularly calomel or blue pill, should be given, and followed, after a few hours, by a stomachic purgative, which should be repeated until a full effect is produced. In these cases, it will oft- en be necessary to repeat the mercurial, as well as the purgative, oftener than once ; the infusion of senna, or equal parts of it and of a tonic infusion, being given with an alkaline car- bonate, or with a neutral salt and the extract of taraxacum, or the bitartrate of potash in large doses, with the confection of senna and this extract. When the headache seems to proceed from an exuberance of acrid bile, then demulcents, with cooling aperients, or with al- kaline carbonates, saline medicines in a state of effervescence, and warm mucilaginous dilu- ents, are generally useful. In cases of this kind, it is necessary to dilute the acrid secre- tions, to evacuate them from the bowels, and to protect the digestive mucous surface from their irritating operation. When the acridity of the bile is the consequence merely of its re- tention and accumulation in the biliary appa- ratus, then these means will be sufficient to re- move disorder; but when it depends upon the exuberance in the blood of the elements whence bile is formed, or upon a morbid action in the liver, a vegetable or farinaceous diet, bland flu- ids, the alkaline carbonates and refrigerants in camphor mixture, regular exercise, especially of the muscles of the upper extremities and of the trunk, are then required. If the action of the liver is not improved by these means, re- course should be had to mercurial alteratives or aperients ; and if it be connected with vas- cular excitement of, or determination to the organ, local depletions, antimonial prepara- tions, diaphoretics and diuretics, external de- rivatives, and the antiphlogistic regimen, should be prescribed. In every case, faecal accumula- tions and morbid secretions should be regular- ly evacuated by the means already advised. 48. E. Organic or Cerebral Headache.—When the patient complains of increased pain in the head on moving it, of spasms or pains in the limbs, or of impaired sensibility of motion of them, of sickness, and of any of the character- istic symptoms of this variety (y 25), deple- tions, general or local, according to the peculi- arities of the case ; deobstruent purgatives, in- ternal and external derivatives, blisters applied on the nape or behind the ears, and kept long discharging, setons or issues, low diet, mental and bodily repose, and local or general refriger- ants, or diaphoretics, as circumstances indi- cate, then constitute the principal means of af- fording relief. After these have removed vas- cular excitement, small doses of the bichloride of mercury, or of the iodide of mercury, or of the iodide of potassium, or of the ioduretted solution of the iodide of potassium, or of the arsenical solution, may be prescribed, and con- tinued until the effects are ascertained; but external derivation should be also persisted in. (See, also, articles Brain, y 211, 222, and Palsy.) 49. F. Pericranial Headache.—When the af- fection proceeds from disease of the pericrani- um or of the cranial bones (y 26), the treatment is essentially the same as that just advised (y 48); but it may be modified to meet various peculiarities and changes. If the affection is syphilitic, the bichloride of mercury, or the io- dide of mercury, or the other preparations of iodine above mentioned, maybe employed. If the periosteum or the bone be diseased, an in- cision should be made down to the affected part, and a free discharge afterward maintain- ed, as successfully practised by Mr. Pearson and Sir B. C. Brodie. If this affection have proceeded from inflammation of the ear, the discharge from the external meatus of the or- gan should be allowed a free egress. (See Ear —Inflammation of, § 26-29.) 50. G. Rheumatic and Arthritic Headaches should be treated with strict reference to the diathesis or constitutional disorder.—a. If rheu- matic headache is not associated with inflamma- tory action of the membranes, the head should be kept warm, and the secretions and excre- tions freely promoted and evacuated. After biliary and faecal accumulations have been car- ried off, camphor, ammonia, and colchicum may be given in conjunction ; or one or more of these may be taken, with bark or any other tonic, or with magnesia, or with the subcar- bonate of soda or potash, especially when the urine deposites a copious sediment or is acid. If severe symptomatic fever or signs of inflam- matory action in the cerebral membranes ac- company the rheumatic affection of the head, local depletions, antimonials, active cathartics, and derivatives should be prescribed, and col- chicum freely exhibited. But when these symp- toms are absent, either of the following medi- cines will generally give relief, a full dose of calomel, or of blue pill with James's powder, or some antimonial, having been taken at bed- time, and a stomachic purgative the following morning, and repeated according to circum- stances : No. 250. R Camphora rasae, Quininae Sulphatis, Pulveris Radicis Colchici, &3 gr xvnj. ; Extracti Hyoscyami 3ss. ; Conserv. Rosar. q. 8. M. Fiant Pilule xxiv., quarum ca- piat duas, bis terve in die.—Vel. No. 251. R Sod* Carbon. 3j.; Tinct. Colchici Comp. 3ss.; Tinct. Cardamom. Co. 3j.; Decocti Cinchona; (vel Infusi Cascarilla;) 3x.; Tinct. Lavandul. Comp. H],xij. M. Fiat Haustus, ter in die sumendus. 51. b. Arthritic headache sometimes requires local depletions from the nape of the neck and from behind the ears, especially in plethoric or robust persons ; but a great quantity of blood should not be taken away. The lower extrem- ities ought to be put in warm water containing flour of mustard and salt; and if the headache is not very much relieved by these means, mustard poultices may be applied to the feet. Colchicum should also be prescribed, with aperi- ent or purgative medicines, and with magnesia, or the alkaline carbonates, as recommended in the article Gout (y 55, 82, et seq.). In these cases, the colchicum, when given in small or suitable doses, and continued for some time, in order to ensure its action on the liver and on the kidneys, seems to favour the elimination of the superabundant urea from the blood; a. 178 HEADACHE—Remedies recommended by Authors. groat excess of this substance in the circula- tion being generally connected with the pro- duction of the gouty affection, in all its modes of manifestation. As urea is the sum or ulti- mate product of assimilation, or results from a combination of the effcete elements of human organization, and as it is liable to accumulate in the blood when the functions of excretion are impaired, owing to weakened organic ner- vous power (see art. Gout, y 40-42), so it is not improbable that, when it is thus superabun- dant, it becomes an excitant not only of mor- bid or altered sensibility, but also of increased vascular action, and of local determination— that, in short, it is the materies morbi of the an- cients, and one of the forms which effcete and excrementitious elements in the blood assume; and that it constitutes a part of the morbid con- dition of which I have shown gout to be the chief manifestation. This view is supported by the experiments of Prout, Chelius, and oth- ers, showing the superabundance of urea, and its combinations in the urine, when the actions of the kidneys are freely exerted, towards the decline of the gouty attack. 52. H. It is unnecessary to enter into the treatment of the other symptomatic varieties of headache, inasmuch as the means of cure for them are essentially the same as are fully sta- ted in the articles on those diseases of which headache is a frequent symptom.—a. When the pain is intermittent, independent of organic lesion, and one of the forms which masked ague assumes, then a full dose of calomel with James's powder, or of any other mercurial al- terative, at bedtime, a brisk cathartic draught early the following morning, and, after the op- eration of these, the sulphate of quinine with camphor, or the preparations of bark and ser- pentaria, will remove the affection.—b. If the headache be hysterical, the means already ad- iviged for nervous headache (y 40) will generally re.medy it. If, however, the pain be sympto- matic of disorder of the uterine or of the urinary functions, the means of cure must be directed to the restoration of these functions to the healthy state, as shown in the articles on Men- struation, Urine, and Uterus ; and to the re- moval of vascular plethora by evacuations and derivatives, especially when the affection de- pends upon this state of the circulation, or ari- ses from suppressed or diminished secretion or excretion, (See Treatment of Plethoric Head- ache, y 45.)—c. The headache attending hypo chondriacal affections is frequently relieved by the means advised for dyspeptic and bilious headaches (y 46); but the .treatment may be conducted in all respects as directed in the ar- ticle on Hypochondriasis.—d. Local or neural- gic headaches (y 35) require the removal of the cause of irritation, when it can be accomplish- ed, and generally the means already advised for the nervous and congestive varieties (y 40- 14); sometimes a constant and energetic ac- tion to be exerted upon the intestinal canal; frequently the exhibition of tonics, stimulants, and narcotics, or anodynes; occasionally ex- ternal irritants or vesicatories, as moxas, cro- ton oil applied to the surface, the tartar emetic ointment, issues, blisters, &c.; in some instan- ces the application of narcotics, as veratria, medical tcieace and to the character of the profession HEARING—Deafness from Affections of the External Ear. 183 affection; the prognosis, under proper treat- ment, is always highly favourable] 6. The Treatment of deafness from this cause consists chiefly of syringing the meatus with tepid water, and of attending to the digestive and excreting functions, and to the general health. Mr. Buchanan recommends a small syringe with a slender point to be employed, fearing that the membrana tympani may be rup- tured by the quantity of fluid injected, and by obstruction to the counter-current by the point of the instrument being too thick. Dr. Kramer, however, considers that this pre- caution is unnecessary, as the membrane can- not be injured by the stream of water, and as the loosened wax will readily flow out with the water. He therefore uses a syringe that will contain an ounce and a half of water, the pipe being three quarters of an inch long, and the opening wide enough for a strong stream. [We sometimes find it necessary to perse- vere for half an hour or more, in injecting luke- warm water into the ear, before the indurated wax will be washed out; the patient, in the mean time, sitting with a wash-hand basin before him, holding his head over it. so that the water thrown into the ear may fall into the vessel. The symptoms, such as tinnitus, deafness, &c, immediately disappear as soon as the wax is removed ; but it is necessary to examine the ear with the speculum or prism, and if we find the walls of the meatus much reddened, it will be useful to drop into the ear a solution con- taining one grain of acetate of lead to an ounce of water ; and if the disease prove obstinate, pustulation, with tartar emetic, may be practised behind the affected ear. Should ulceration ex- ist, it only requires to be smeared with tincture of myrrh, or tinctureffcf opium.] 7. B. Deafness from inflammation of the folli- cles of the auditory passage seldom is considera- ble, until the inflammatory action has given rise to some lesion of structure. Mucous or catarrhal otorrhcea (see art. Ear, § 18) is caused by the affection of these glands. From this in- flammation, and from that of the membrana tym- pani, various excrescences* or morbid growths in the meatus ultimately proceed. On inspec- tion, redness and partial swelling of the walls of the passage are first observed; and, if the affection continues long, or becomes chronic, excrescences, or polypi, of a soft, spongy, or vesicular appearance, are gradually formed. These are red, sensitive, roundish, peduncu- lated, and readily bleed when irritated. In some cases, they have a broad, hard base, are insensible, and not disposed to bleed. These obstruct more or less the meatus, and impede the functions of the organ. Hardened mucus and wax may also accumulate in the passage, as a consequence of the chronic states of this affection, and of the obstruction caused by these excrescences. [Kramer is very positive that this affection, even in its worst form, rarely, if ever, extends beyond the limits of the glandular structure; and never inducing ulceration, destroying the membrana tympani, or extending to the bone. * iThe terms polypus, fungus, and vegetation are applied indiscriminately to these morbid growths. (See A Treatise mi the Structure, Economy, and Diseases of the Ear ; being th> Essay for which the Fathergillian Geld Medal was awarded by the Medical Society of London, by George Filches, 1st Am. Ed., Philadelphia, 1843J] He admits, however, that it is possible, when the secretion from the glandular structure be- comes suppressed, the inflammatory action may be increased, and extend not only to the inter- nal ear, but to the brain, endangering the life of the patient.*] 8. The Treatment of this disease should be directed according to the method just advised ($ 6). The extirpation of the fungous growth should be performed ; but, as M. Itard has stated, the deafness may continue neverthe- less ; for the membrane of the drum may be thickened, or ulcerated, or covered by inspis- sated secretions ; and otorrhcea will often long remain. In these cases, injections of tepid water, or of emollient and diluent fluids; blis- ters on the nape, and kept open, or setons or issues, and the means advised for the removal of mucous otorrhaa (see art. Ear, y 29), should be prescribed. [Polypi of the ear, especially if pedunculated, can readily be reached, either with the ligature, or with a pair of finely made scissors with curv ed blades, or with a double-edged knife, simi- larly curved, having a blunt and rounded ex- tremity, or with a pair of delicate forceps, fur- nished at their extremities with several sharp points, in order to lay hold of the polypus, and either twist it off, or tear it out. After it has been removed, it will be useful to touch the root, or place of attachment, with the solid nitrate of silver, which should be in the form of a very thin stick, scarcely a quarter of a line in diameter, and placed in a holder bent in a zigzag form, and provided with a ferule of platina at its extremity. For this operation, a full, bright light will be necessary. Kramer recommends an injection of a solution of the acetate of lead into the affected ear (gr. x. to 5J. water), where the polypus sprouts up, not- i withstanding the use of the caustic.—(Loc. cit.) In the removal of these polypi, especially by the forceps, great care is necessary lest the membrana tympani be implicated, and violence be done to this part by the operation ; by which severe inflammation may be excited, produc- tive of dangerous consequences. Excision is to be used where the polypus projects so far outward as to allow the forceps or the scissors to be passed to its pedicle ; if not, we must re- sort to the careful use of escharotics] 9. C. Deafness caused by phlegmonous inflam- mation of the cellular tissue of the passage rarely occurs; but this affection may be mistaken for the preceding ; from which, however, it is read- ily distinguished by its rapid course, and ter- mination in abscess—results never observed in inflammation of the follicles. Owing to the severity of the pain, and other symptoms, it may be confounded with inflammation of the internal ear; but in this case, the external pas- sage never presents any lesion on inspection, at least at the commencement. This disease is usually caused by cold or currents of air. The treatment is altogether the same as recommend- ed for external acute Otitis (see Ear, § 27). 10. D. Inflammation of the periosteum of the passage is most common in children of a scrof- ulous diathesis, and generally occasions caries of the bony structure, which is readily detected * [*' Nature and Treatment of Diseases of the Ear, by Dr. William Kramer." Tianslated from the German by James Risdon Benhett, M.D. Philadelphia, 1638] 184 HEARING—Deafness from Affections of the External Ear. with the probe. If exfoliation of the diseased bone occur, and the ulcerated part begins to heal, narrowing or obliteration of the meatus may take place. In these cases, the deafness often depends as much upon congestion of the adjoining parts as upon swelling and disease of the passage. Dr. Kramer advises, in the treatment, that, when the parts show a tenden- cy to close, they should be opened up by art, and maintained open by touching them with lunar caustic throughout their extent. Hear- ing, however, usually continues very dull, ow- ing to the natural form of the meatus having been lost, and to the membrane of the drum having become thickened. 11. E. Deafness from Disease of the Membrane of the Drum.—It has been supposed that relax- ation of this membrane, that too great tension of it, that rupture of it, and that rupture of the tendon of the tensor tympani, may severally occasion impaired hearing. Cleland, Saissy, Beck, and others think that these lesionsimay be produced by violent sneezing, by claps of thunder, by noises of artillery, &c. ; but, as Kramer contends, these suppositions are un- founded, rupture of these parts never occur- ring unless from inflammation and its conse- quences He remarks that perforation of the membrane is in rare cases met with, little or no mucous or purulent discharge having been observed; but, even in these, upon examina- tion, in a bright sunshine, with the speculum, a viscid, mucous, or puriform matter is always found at the bottom, and the remaining portion of the membrane is seen reddened, thickened, and opaque. 12. a. Inflammation of the membrane of the tympanum most frequently occurs in connexion with inflammation of one or other of the struc- tures of the meatus, especially of the follicles. It may, however, take place primarily, and con- stitute the chief affection. Acute inflammation of this part is not so common as the sub-acute and chronic states ; and either, when neglect- ed, gives rise to opacity, thickening, perfora- tion, purulent discharge, fungous or polypous excrescences, &c.; but the chronic states most frequently induce these lesions. In acute in- flammation, the membrane is seen, on careful examination, more or less red, rough, swollen, and opaque. It often seems as if covered with small projecting glands or follicles. Sometimes bundles of vessels are seen in it, and the point of insertion of the handle of the malleus can- not be distinguished. Dr. Kramer states that inflammations of this part' are distinguished from internal inflammations of the ear, not only by the greater mildness of the former, but especially by the changes of the membrane presented by them from the commencement; whereas, in the latter, such changes cannot be detected early in the disease, however violent the symptoms and attendant fever may be ; and occur only in the farther course of the malady, when the membrane is about to burst, from the pressure of accumulated matter, or has become involved in the inflammatory process. The different grades of this disease have been im- puted to nervous otalgia, or confounded with it. Dr. Kramer, however, denies the existence of such an affection. In this he is evidently mis- taken (see Ear, $ 6); although it must be ad- mitted that both this, and other inflammatory diseases of the ear, are often improperly view- ed as nervous merely. The hardened secretion in the meatus, to which the more chronic states of inflammation of the membrane have been imputed, is more commonly the result of in- flammatory action than its cause. The dis- ease, in both its primary and its consecutive states, generally impairs hearing more or less. [It is important that the practitioner should be fully acquainted with the symptoms of this affection, so often mistaken for pure nervous otalgia, or earache, as its successful treatment will depend on such discrimination. When inflammation occurs in the tympanitic mem- brane, the patient suddenly feels an acute pain at the bottom of the meatus, following the ap- plication of some irritant, as cold wind striking sharply against the membrane ; the introduc- tion of some foreign body, as insects, &c. ; or mechanical injury resulting from the removal of hard wax or a foreign substance ; or too violent and sudden noise. The pain is accom- panied by buzzings, as if something were flut- tering in the ear, and by a lessened capability of hearing; and it is increased by loud sounds, by variations of temperature, and by pressure upon the ear. If we examine the tympanum by means of the speculum, or aural prism, we shall find it slightly reddened in mild cases, but intensely so in severe ones, the blood-ves- sels being distinctly visible.] 13. The Treatment is the same in this as in the other inflammatory diseases of the meatus, and as directed for inflammations of the external Ear ($ 27, 29). Dr. Kramer, however, prefers injections containing the acetate of lead, and pours a solution, varying in strength, from one grain to ten of the salt to an ounce of water, into the diseased ear twice or thrice a day. Injections of a solution of the nitrate of silver, or of the sulphate of zinc, or of alum, have been also recommended; but unless they be weak, they often occasion pain and irritation in the meatus. A few drops of pyroligneous acid to an ounce of water have likewise been used as an injection. Both it and the acetate of lead will effectually remove the offensive odour of the discharge. [Our own experience in the treatment of this affection leads us to the belief that stim- ulating applications, as advised above by Kra- mer, are extremely hazardous, and not to be compared with those of a soothing and emoll- ient kind. The warmth and moisture of a poultice, applied between two pieces of muslin over the affected ear, or the pulp of a roasted onion, bound over the same part, aided by a pur- gative, to be followed by a Dover's powder in the evening, will generally prove successful in removing the malady. If the symptoms per- sist, and are of a severe character, general or local bleeding, or both, will be advisable, with a strict antiphlogistic regimen ; and if the dis- ease threatens to become chronic, a blister behind the ear, and kept discharging by means of the Savine ointment, will prove useful. Un- der such circumstances, Pilcher recommends salivation, but if the foregoing means are faith- fully used, it will rarely be found necessary] 14. b. Deafness from' PcTfymtion of the Mem- brane of the^rmnyf-Wv.ame* Aa*?)^' that many authori, jfnjJMmong them even Wrd, are of opinion ihw Perforation of this meiibr^ne does I v^ "wn -^ S I V fin %. \.f $? % i W fil "V 1 ^ J / / i>v \ \ lo. ifi v^ "X / ** fw: \«* ran ^» rw^; w , /CiL-iX /«*JBfc\ /r4n\ /<* /% i^9R«i ^N^, L8LI >% is^ffei y^ ? v try. X^ '*)' X .